Provider Demographics
NPI:1417566936
Name:SHATTUCK, ANN (APRN)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751874
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1874
Mailing Address - Country:US
Mailing Address - Phone:843-402-5200
Mailing Address - Fax:
Practice Address - Street 1:2910 TRICOM ST STE 100
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9351
Practice Address - Country:US
Practice Address - Phone:843-572-9211
Practice Address - Fax:843-572-0457
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2022-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24125363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP6971Medicaid