MEDICARE: SHANICE MARY ANN MATOS PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	5017790	NC

General Provider Information

NPI Number	:	1427759059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANICE MARY ANN MATOS PMHNP

Provider Business Mailing Address
First Line	:	350 ROYAL BIRKDALE DR
Second Line	:
City	:	RAEFORD
State	:	NC
Zip	:	28376-8956
Country	:	US
Telephone Number	:	917-251-1167
Fax Number	:

Provider Business Practice Location Address
First Line	:	711 EXECUTIVE PL FL 4
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28305-5193
Country	:	US
Telephone Number	:	910-615-3333
Fax Number	:	910-615-1623

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2023
Last Update Date	:	02/25/2026

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