Provider Demographics
NPI:1124612452
Name:BREEZE, SHANTELLE NICOLLE (AGNP)
Entity type:Individual
Prefix:MRS
First Name:SHANTELLE
Middle Name:NICOLLE
Last Name:BREEZE
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 POMONA DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1619
Mailing Address - Country:US
Mailing Address - Phone:336-282-0132
Mailing Address - Fax:
Practice Address - Street 1:203 POMONA DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1619
Practice Address - Country:US
Practice Address - Phone:336-282-0132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBREE-0E05L363LA2200X
NC264125163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical