Healthcare Provider Details

I. General information

NPI: 1023589454
Provider Name (Legal Business Name): JASMINE DIANE MCCORKLE SHYTLE WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3292 PEORIA ST
AURORA CO
80010-1517
US

IV. Provider business mailing address

475 TRIBBLE GAP RD
CUMMING GA
30040-2478
US

V. Phone/Fax

Practice location:
  • Phone: 303-360-6276
  • Fax: 303-789-7222
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN241143
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN241143
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberC-APN.0002514-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: