Healthcare Provider Details

I. General information

NPI: 1366014854
Provider Name (Legal Business Name): SHAKYRA TATYANA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1799 EDGEFIELD RD STE A
NORTH AUGUSTA SC
29860-5306
US

IV. Provider business mailing address

1799 EDGEFIELD RD STE A
NORTH AUGUSTA SC
29860-5306
US

V. Phone/Fax

Practice location:
  • Phone: 803-341-8343
  • Fax:
Mailing address:
  • Phone: 803-341-8343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: