Healthcare Provider Details

I. General information

NPI: 1487195145
Provider Name (Legal Business Name): SHELLEY ANDERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2017
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 MILSTEAD AVE NE
CONYERS GA
30012-3877
US

IV. Provider business mailing address

59 CEDAR PT
DALLAS GA
30132-1096
US

V. Phone/Fax

Practice location:
  • Phone: 770-918-8079
  • Fax:
Mailing address:
  • Phone: 678-823-5699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8319
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number8319
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: