Healthcare Provider Details

I. General information

NPI: 1093069627
Provider Name (Legal Business Name): SHASTA LEANN EBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 01/03/2024
Certification Date: 03/10/2022
Deactivation Date: 02/03/2022
Reactivation Date: 02/23/2022

III. Provider practice location address

125 DAYS INN DR
MOORESVILLE NC
28117-6323
US

IV. Provider business mailing address

5415 PECANBLUFF CT
CHARLOTTE NC
28216-2662
US

V. Phone/Fax

Practice location:
  • Phone: 704-660-9111
  • Fax: 704-663-4504
Mailing address:
  • Phone: 704-560-9158
  • Fax: 336-277-4672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5005908
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: