Healthcare Provider Details

I. General information

NPI: 1750957239
Provider Name (Legal Business Name): DR. SHANNON JEFFERY HEATON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N COX ST STE 28
ASHEBORO NC
27203-5514
US

IV. Provider business mailing address

1826 SUNSET BELT
ROCKINGHAM NC
28379-2743
US

V. Phone/Fax

Practice location:
  • Phone: 336-792-4062
  • Fax: 336-629-9500
Mailing address:
  • Phone: 910-995-4259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5014494
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: