Basic Information
| Provider Information | |||||||||
| NPI: | 1245612506 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUSKEY | ||||||||
| FirstName: | SHAMIKA | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 WALTER REED DR | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274031128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368329700 | ||||||||
| FaxNumber: | 3368329614 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MEDICAL PARK DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280250939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047861108 | ||||||||
| FaxNumber: | 7047821826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2015 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/11/2021 | ||||||||
| NPIReactivationDate: | 11/28/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5007699 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 5007699 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2097433 | 05 | NC | MEDICAID |