Healthcare Provider Details

I. General information

NPI: 1629041355
Provider Name (Legal Business Name): SHIRLEY LAVON HARRELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHIRLEY LAVON KNOWLES HARRELL NP

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 OCILLA RD
DOUGLAS GA
31533-2207
US

IV. Provider business mailing address

PO BOX 1227
DOUGLAS GA
31534-1227
US

V. Phone/Fax

Practice location:
  • Phone: 912-384-1900
  • Fax: 912-389-2112
Mailing address:
  • Phone: 912-384-1900
  • Fax: 912-389-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN056220
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN056220
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: