Healthcare Provider Details

I. General information

NPI: 1720991250
Provider Name (Legal Business Name): SHANTRELLA PENSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 HUNTINGTON PL CT
MCDONOUGH GA
30253
US

IV. Provider business mailing address

885 HALL ST
MACON GA
31217-6456
US

V. Phone/Fax

Practice location:
  • Phone: 678-782-6920
  • Fax:
Mailing address:
  • Phone: 478-538-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP289400
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: