Provider Demographics
NPI:1134873961
Name:RICKERTS, SHAUNA MACKENZIE (RN, BSN)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:MACKENZIE
Last Name:RICKERTS
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:SHAUNA
Other - Middle Name:MACKENZIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:501 20TH ST STE 606
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1863
Mailing Address - Country:US
Mailing Address - Phone:865-331-2278
Mailing Address - Fax:
Practice Address - Street 1:2317 DECLARATION DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5638
Practice Address - Country:US
Practice Address - Phone:336-420-5970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC277884163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse