Healthcare Provider Details

I. General information

NPI: 1649062548
Provider Name (Legal Business Name): SHAUN A. CUMBERMACK DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 WHEELER RD STE 1A
AUGUSTA GA
30909-6596
US

IV. Provider business mailing address

3665 WHEELER RD STE 1A
AUGUSTA GA
30909-6596
US

V. Phone/Fax

Practice location:
  • Phone: 706-825-4691
  • Fax:
Mailing address:
  • Phone: 706-250-3902
  • Fax: 706-303-4668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN240547
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: