Healthcare Provider Details

I. General information

NPI: 1508442732
Provider Name (Legal Business Name): STACEY SHELDON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 SANDY PLAINS RD
MARIETTA GA
30066-3020
US

IV. Provider business mailing address

3600 SANDY PLAINS RD
MARIETTA GA
30066-3020
US

V. Phone/Fax

Practice location:
  • Phone: 770-977-4547
  • Fax: 770-977-8354
Mailing address:
  • Phone: 770-977-4547
  • Fax: 770-977-8354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11047
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9114073
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: