Provider Demographics
NPI:1508369109
Name:AUGUSTINE, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4136 WOODGREEN TER
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-4666
Mailing Address - Country:US
Mailing Address - Phone:703-389-2063
Mailing Address - Fax:
Practice Address - Street 1:1212 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4215
Practice Address - Country:US
Practice Address - Phone:704-334-8087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-10
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR231979363LF0000X
NC5012130363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily