Healthcare Provider Details

I. General information

NPI: 1467840272
Provider Name (Legal Business Name): SHANIKA LINETTE RICHARDSON CONYERS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2014
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 S LIBERTY ST
WAYNESBORO GA
30830-9686
US

IV. Provider business mailing address

1120 15TH ST STE BI1056
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-554-2176
  • Fax:
Mailing address:
  • Phone: 706-554-4435
  • Fax: 706-437-2680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number22222
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN225002
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: