Healthcare Provider Details

I. General information

NPI: 1881188779
Provider Name (Legal Business Name): SHANA DANIELLE HUTTO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 VERNON WILLIAMS RD
HAZLEHURST GA
31539-7887
US

IV. Provider business mailing address

210 HILLSBORO RD
LYONS GA
30436-4646
US

V. Phone/Fax

Practice location:
  • Phone: 912-750-8801
  • Fax: 912-705-8851
Mailing address:
  • Phone: 912-245-1577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN170590
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: