=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013634302
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELBY LEE PRITCHETT FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2022
-----------------------------------------------------
Last Update Date | 01/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 865 AUSTIN DR
-----------------------------------------------------
City | DEMOREST
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30535-4513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-949-0174
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1076 MERCK RD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30528-7435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-768-7628
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN286251
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------