Healthcare Provider Details

I. General information

NPI: 1316545585
Provider Name (Legal Business Name): SHARA LISETTE LACCONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2020
Last Update Date: 10/11/2020
Certification Date: 10/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 HIDDEN VALLEY DR
CHAPEL HILL NC
27516-8949
US

IV. Provider business mailing address

488 BEACON RIDGE BLVD
CHAPEL HILL NC
27516-9820
US

V. Phone/Fax

Practice location:
  • Phone: 912-882-9293
  • Fax:
Mailing address:
  • Phone: 912-882-9293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number5013447
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: