{
"Npi": {
"NPI": "1093286015",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "KING",
"FirstName": "SHADARA",
"MiddleName": null,
"NamePrefix": "MRS.",
"NameSuffix": null,
"Credential": "AGNP-C",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "EDMOND",
"OtherFirstName": "SHADARA",
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "185 TIMBER WOLF XING",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GARNER",
"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "27529-9279",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "302-228-6434",
"MailingAddressFaxNumber": "910-348-7961",
"FirstLinePracticeLocationAddress": "3214 CHARLES B ROOT WYND STE 203",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "RALEIGH",
"PracticeLocationAddressStateName": "NC",
"PracticeLocationAddressPostalCode": "27612-5440",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "919-877-6800",
"PracticeLocationAddressFaxNumber": "844-881-7701",
"EnumerationDate": "12/17/2018",
"LastUpdateDate": "07/07/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "363L00000X",
"TaxonomyName": "Nurse Practitioner",
"LicenseNumber": "LP-0010645",
"LicenseNumberStateCode": "DE",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363L00000X",
"TaxonomyName": "Nurse Practitioner",
"LicenseNumber": "33592",
"LicenseNumberStateCode": "TN",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363L00000X",
"TaxonomyName": "Nurse Practitioner",
"LicenseNumber": "27576",
"LicenseNumberStateCode": "SC",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363L00000X",
"TaxonomyName": "Nurse Practitioner",
"LicenseNumber": "3-001270",
"LicenseNumberStateCode": "AL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363LA2200X",
"TaxonomyName": "Adult Health Nurse Practitioner",
"LicenseNumber": "5011293",
"LicenseNumberStateCode": "NC",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363LA2200X",
"TaxonomyName": "Adult Health Nurse Practitioner",
"LicenseNumber": "AG03180040",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363L00000X",
"TaxonomyName": "Nurse Practitioner",
"LicenseNumber": "5011293",
"LicenseNumberStateCode": "NC",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}