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General NPI Number Information
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NPI Number | 1093069627
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Entity Type | Individual
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Provider Name | SHASTA LEANN EBERT
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Gender | Female
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Dates
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Enumeration Date | 11/05/2012
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Last Update Date | 01/03/2024
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Provider Practice Location Address
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Address Line | 125 DAYS INN DR
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City | MOORESVILLE
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State | NC
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Zip | 28117-6323
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Country | US
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Telephone | 704-660-9111
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Fax | 704-663-4504
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Provider Business Mailing Address
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Address Line | 5415 PECANBLUFF CT
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City | CHARLOTTE
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State | NC
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Zip | 28216-2662
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Country | US
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Telephone | 704-560-9158
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Fax | 336-277-4672
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 5005908
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License Number State | NC
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