Provider Demographics
NPI:1982303368
Name:EASLEY, SHALISSA MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHALISSA
Middle Name:MARIE
Last Name:EASLEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 W PEORIA AVE STE C500
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4600
Mailing Address - Country:US
Mailing Address - Phone:623-773-2000
Mailing Address - Fax:
Practice Address - Street 1:3201 W PEORIA AVE STE C500
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4600
Practice Address - Country:US
Practice Address - Phone:623-773-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ287086363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily