Provider Demographics
NPI:1922396696
Name:SHEALY, SUSAN STACKER (APRN MSN CPNP PC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:STACKER
Last Name:SHEALY
Suffix:
Gender:F
Credentials:APRN MSN CPNP PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 OLD FURNACE RD
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29316-5782
Mailing Address - Country:US
Mailing Address - Phone:864-578-8720
Mailing Address - Fax:864-599-5675
Practice Address - Street 1:1307 N LOGAN ST
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-2026
Practice Address - Country:US
Practice Address - Phone:864-488-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-15
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN.17546 RX363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics