Healthcare Provider Details

I. General information

NPI: 1528908407
Provider Name (Legal Business Name): MISS SHANTAYE T FELTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1146 FELDMAN CHASE
LOGANVILLE GA
30052-4849
US

IV. Provider business mailing address

1146 FELDMAN CHASE
LOGANVILLE GA
30052-4849
US

V. Phone/Fax

Practice location:
  • Phone: 856-419-1827
  • Fax:
Mailing address:
  • Phone: 856-419-1827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: