Healthcare Provider Details

I. General information

NPI: 1295329332
Provider Name (Legal Business Name): SHANNON GAYDESKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 NEW BRIDGE ST
JACKSONVILLE NC
28540-4756
US

IV. Provider business mailing address

310 NEW BRIDGE ST
JACKSONVILLE NC
28540-4756
US

V. Phone/Fax

Practice location:
  • Phone: 910-621-4266
  • Fax: 910-613-0382
Mailing address:
  • Phone: 910-621-4266
  • Fax: 910-613-0382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-107778
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: