Provider Demographics
NPI:1972241842
Name:HUMPHREY, SHAWANNA MONIQUE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHAWANNA
Middle Name:MONIQUE
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SHAWANA
Other - Middle Name:MONIQUE
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:674 RIVER DELL TOWNES AVE
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-8922
Mailing Address - Country:US
Mailing Address - Phone:919-288-6197
Mailing Address - Fax:
Practice Address - Street 1:23 SUNNYBROOK RD STE 116
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-7401
Practice Address - Country:US
Practice Address - Phone:919-250-3478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-21
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5016218363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily