Healthcare Provider Details

I. General information

NPI: 1891608774
Provider Name (Legal Business Name): SHELLI-ANN MCKENZIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHELLI-ANN JACKSON

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1971 BIRCH CREST PL
DACULA GA
30019-3305
US

IV. Provider business mailing address

600 W PEACHTREE ST NW STE 1700-106
ATLANTA GA
30308-3607
US

V. Phone/Fax

Practice location:
  • Phone: 646-420-0190
  • Fax:
Mailing address:
  • Phone: 646-420-0190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN180684
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN180684
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License NumberRN180684
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN180684
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: