Provider Demographics
NPI:1770311862
Name:KING, SHAINA A (MSN, PHMNP-BC)
Entity type:Individual
Prefix:
First Name:SHAINA
Middle Name:A
Last Name:KING
Suffix:
Gender:F
Credentials:MSN, PHMNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12412 TIMBERLAND BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5228
Mailing Address - Country:US
Mailing Address - Phone:682-593-6001
Mailing Address - Fax:
Practice Address - Street 1:250 W SOUTHLAKE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6170
Practice Address - Country:US
Practice Address - Phone:817-997-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1168756363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health