Healthcare Provider Details

I. General information

NPI: 1437011079
Provider Name (Legal Business Name): SHA'TEIRA KEYAJI BURNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 BUNK TILLMAN RD
MONROE GA
30656-4901
US

IV. Provider business mailing address

3110 BUNK TILLMAN RD
MONROE GA
30656-4901
US

V. Phone/Fax

Practice location:
  • Phone: 404-732-2541
  • Fax:
Mailing address:
  • Phone: 404-732-2541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT013745
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: