MEDICARE: SHAMICHAEL FLAGG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	330094	NY
2	164W00000X	Licensed Practical Nurse	091380	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	091380	OTHER	NC	NURSING LICENSE

General Provider Information

NPI Number	:	1376209528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAMICHAEL FLAGG

Provider Business Mailing Address
First Line	:	1520 IVY MEADOW DR APT 924
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-9035
Country	:	US
Telephone Number	:	315-876-4664
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 IVY MEADOW DR APT 924
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-9035
Country	:	US
Telephone Number	:	315-876-4664
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2021
Last Update Date	:	11/11/2021

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Directions to “ SHAMICHAEL FLAGG ” Practice Location

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