=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326798471
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANTESE COLEMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2022
-----------------------------------------------------
Last Update Date | 03/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11340 LAKEFIELD DR
-----------------------------------------------------
City | JOHNS CREEK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-1714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-670-1014
-----------------------------------------------------
Fax | 470-666-1979
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11340 LAKEFIELD DR
-----------------------------------------------------
City | JOHNS CREEK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-1714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-670-1014
-----------------------------------------------------
Fax | 470-666-1979
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | CN0014203472
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------