Healthcare Provider Details

I. General information

NPI: 1750939856
Provider Name (Legal Business Name): SHACEDA MANSFIELD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2019
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N JACKSON ST STE B
AMERICUS GA
31719-3089
US

IV. Provider business mailing address

204 FRIEDA LN
AMERICUS GA
31709-3230
US

V. Phone/Fax

Practice location:
  • Phone: 229-931-0446
  • Fax:
Mailing address:
  • Phone: 229-815-9390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN184284
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN184284
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: