Healthcare Provider Details

I. General information

NPI: 1568331767
Provider Name (Legal Business Name): RUTH-ANN SAMANTHA SHACKLEFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 GWINNETT DR
LAWRENCEVILLE GA
30046-5629
US

IV. Provider business mailing address

311 GWINNETT DR
LAWRENCEVILLE GA
30046-5629
US

V. Phone/Fax

Practice location:
  • Phone: 770-910-9196
  • Fax:
Mailing address:
  • Phone: 770-910-9196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP287472
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: