Healthcare Provider Details

I. General information

NPI: 1093796153
Provider Name (Legal Business Name): INEZ IDA SHANKS REGISTER NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE STE 1 D03
FORT STEWART GA
31314-5604
US

IV. Provider business mailing address

971 FOX HAVEN CT
HINESVILLE GA
31313-4950
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-6933
  • Fax:
Mailing address:
  • Phone: 912-369-3383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number163WC1500X
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: