Provider Demographics
NPI:1407447352
Name:YOUNG, SHAREDA MICKELLE (NP)
Entity Type:Individual
Prefix:
First Name:SHAREDA
Middle Name:MICKELLE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 JEWELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29365-1351
Mailing Address - Country:US
Mailing Address - Phone:864-331-9851
Mailing Address - Fax:
Practice Address - Street 1:3070 REIDVILLE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-5642
Practice Address - Country:US
Practice Address - Phone:864-576-5764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24150363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1194729715Medicaid