Provider Demographics
NPI:1639795859
Name:SALLEY, SHATARRA TAVONIA (APRN, FNP-C, PMHNP)
Entity type:Individual
Prefix:MRS
First Name:SHATARRA
Middle Name:TAVONIA
Last Name:SALLEY
Suffix:
Gender:
Credentials:APRN, FNP-C, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749306
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9306
Mailing Address - Country:US
Mailing Address - Phone:864-968-9144
Mailing Address - Fax:864-968-9244
Practice Address - Street 1:1762 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-2231
Practice Address - Country:US
Practice Address - Phone:864-968-9144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24906363LP0808X, 363LF0000X
NC24906363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily