Healthcare Provider Details

I. General information

NPI: 1134541097
Provider Name (Legal Business Name): SHONTREKA AKISHA GLOVER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N PARK TRL STE B
STOCKBRIDGE GA
30281-7372
US

IV. Provider business mailing address

1001 SUMMIT BLVD STE 200
BROOKHAVEN GA
30319-6410
US

V. Phone/Fax

Practice location:
  • Phone: 770-507-0909
  • Fax: 770-507-1919
Mailing address:
  • Phone: 770-989-1668
  • Fax: 678-388-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN 155519
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: