Provider Demographics
NPI:1629265483
Name:GREGG, SHAWNTE RENEE (NP)
Entity Type:Individual
Prefix:MS
First Name:SHAWNTE
Middle Name:RENEE
Last Name:GREGG
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 1:4688 W TANGERINE RD APT 12208
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85658-4890
Mailing Address - Country:US
Mailing Address - Phone:765-215-7332
Mailing Address - Fax:
Practice Address - Street 1:4688 W TANGERINE RD APT 12208
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85658-4890
Practice Address - Country:US
Practice Address - Phone:765-215-7332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002489A363LF0000X, 363L00000X
AZAP9774363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200875520Medicaid
IN200875520Medicaid