Provider Demographics
NPI:1962825034
Name:THOM, SHANTELLA EVETTE
Entity Type:Individual
Prefix:MRS
First Name:SHANTELLA
Middle Name:EVETTE
Last Name:THOM
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 1:6361 DAY LILLY LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-8839
Mailing Address - Country:US
Mailing Address - Phone:704-771-0522
Mailing Address - Fax:
Practice Address - Street 1:2485 HEMBY LN
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3701
Practice Address - Country:US
Practice Address - Phone:888-549-1922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100037367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered