Provider Demographics
NPI:1023470689
Name:WARD, SHAUNTAVIA (FNP-C)
Entity type:Individual
Prefix:
First Name:SHAUNTAVIA
Middle Name:
Last Name:WARD
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SHAUNTAVIA
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:4515 SETON CENTER PKWY STE 215
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5785
Mailing Address - Country:US
Mailing Address - Phone:512-231-5507
Mailing Address - Fax:
Practice Address - Street 1:6835 AUSTIN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3166
Practice Address - Country:US
Practice Address - Phone:512-346-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008341363LF0000X
TXAP130140363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX380586301Medicaid
TX380586302Medicaid