Provider Demographics
NPI:1639795859
Name:SALLEY, SHATARRA TAVONIA (APRN, FNP-C, PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:SHATARRA
Middle Name:TAVONIA
Last Name:SALLEY
Suffix:
Gender:F
Credentials:APRN, FNP-C, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 COMMONS WAY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611-3850
Mailing Address - Country:US
Mailing Address - Phone:864-520-2020
Mailing Address - Fax:864-640-4400
Practice Address - Street 1:2400 BOILING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BOILING SPRINGS
Practice Address - State:SC
Practice Address - Zip Code:29316-5304
Practice Address - Country:US
Practice Address - Phone:864-599-0731
Practice Address - Fax:864-599-0791
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24906363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily