Healthcare Provider Details

I. General information

NPI: 1710694716
Provider Name (Legal Business Name): SHAMARRA JACKSON FARMER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 WINDMEADOW WAY
FAYETTEVILLE GA
30214-5313
US

IV. Provider business mailing address

133 WINDMEADOW WAY
FAYETTEVILLE GA
30214-5313
US

V. Phone/Fax

Practice location:
  • Phone: 404-788-5078
  • Fax:
Mailing address:
  • Phone: 404-788-5078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number207756
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: