Healthcare Provider Details

I. General information

NPI: 1699590224
Provider Name (Legal Business Name): SHANTONIA MARIA WEAVER MLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11935 ABERCORN ST
SAVANNAH GA
31419-1918
US

IV. Provider business mailing address

3721 SALEM CHAPEL DR
LITHONIA GA
30038-4837
US

V. Phone/Fax

Practice location:
  • Phone: 912-478-4636
  • Fax:
Mailing address:
  • Phone: 678-979-6538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: