Healthcare Provider Details

I. General information

NPI: 1821724790
Provider Name (Legal Business Name): MICHAEL SHASTEL PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 09/06/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WISTERIA DR
GAINESVILLE GA
30501-3827
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-5407
  • Fax:
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN246991
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN246991
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: