Provider Demographics
NPI:1366014854
Name:OSEITUTU, SHAKYRA
Entity type:Individual
Prefix:
First Name:SHAKYRA
Middle Name:
Last Name:OSEITUTU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 COMMUNITY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-8131
Mailing Address - Country:US
Mailing Address - Phone:309-558-5888
Mailing Address - Fax:
Practice Address - Street 1:115 COMMUNITY RD
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29860-8131
Practice Address - Country:US
Practice Address - Phone:309-558-5888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC171400000X, 133N00000X, 133NN1002X
133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC302611321Medicaid
SC850000309Medicaid