Provider Demographics
NPI:1003647363
Name:BALLARD, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BALLARD
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 1:4800 TREVETT CIR
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-9778
Mailing Address - Country:US
Mailing Address - Phone:919-809-0442
Mailing Address - Fax:
Practice Address - Street 1:4800 TREVETT CIR
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-9778
Practice Address - Country:US
Practice Address - Phone:919-809-0442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider