Basic Information
| Provider Information | |||||||||
| NPI: | 1326563909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLTSCLAW | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LEA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR STE 100 | ||||||||
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| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 BEECH ST | ||||||||
| Address2: | |||||||||
| City: | NEWLAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286579670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287335889 | ||||||||
| FaxNumber: | 8287338743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2017 | ||||||||
| LastUpdateDate: | 08/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0809X | 172290 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
No ID Information.