Provider Demographics
NPI:1467130831
Name:SHUMATE, MANDY SUZANNE ELLER (FNP)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:SUZANNE ELLER
Last Name:SHUMATE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 ARNOLD JONES RD
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:NC
Mailing Address - Zip Code:28615-9001
Mailing Address - Country:US
Mailing Address - Phone:336-977-0814
Mailing Address - Fax:
Practice Address - Street 1:148 HIGHWAY 105 EXT STE 102
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5682
Practice Address - Country:US
Practice Address - Phone:336-386-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5018407363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner