Healthcare Provider Details

I. General information

NPI: 1255825832
Provider Name (Legal Business Name): SHANNON LOUETTE SKAUG CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 FIRST VILLAGE DR
PINEHURST NC
28374-9495
US

IV. Provider business mailing address

PO BOX 2000
PINEHURST NC
28374-2000
US

V. Phone/Fax

Practice location:
  • Phone: 910-235-2709
  • Fax: 910-215-3080
Mailing address:
  • Phone: 910-235-2709
  • Fax: 910-215-3080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5013285
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-153334
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: