MEDICARE: MRS. SHANICE THURMOND PA-C

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207V00000X	Obstetrics & Gynecology Physician	9934	GA

General Provider Information

NPI Number	:	1336793710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANICE THURMOND PA-C

Provider Business Mailing Address
First Line	:	6558 ROSWELL RD APT 1168
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-5071
Country	:	US
Telephone Number	:	414-698-9920
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 TALMADGE RD
Second Line	:
City	:	HAMPTON
State	:	GA
Zip	:	30228-1608
Country	:	US
Telephone Number	:	404-564-7005
Fax Number	:

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

Provider Enumeration Date	:	07/24/2019
Last Update Date	:	03/10/2021

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