Healthcare Provider Details

I. General information

NPI: 1205378247
Provider Name (Legal Business Name): SHANNON BROOKE LITTLE RN; BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 SIGNAL HILL DRIVE EXT
STATESVILLE NC
28625-4391
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR SUITE 100
CONCORD NC
28025-1894
US

V. Phone/Fax

Practice location:
  • Phone: 704-871-1045
  • Fax: 704-873-6647
Mailing address:
  • Phone: 704-939-1100
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number177415
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: