Healthcare Provider Details

I. General information

NPI: 1194474882
Provider Name (Legal Business Name): SHANTELLE K GRIFFITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 CLIFTON RD NE STE 105
ATLANTA GA
30322-4200
US

IV. Provider business mailing address

1525 CLIFTON RD NE STE 105
ATLANTA GA
30322-4200
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3333
  • Fax:
Mailing address:
  • Phone: 404-778-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number112649
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number112649
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: