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General NPI Number Information
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NPI Number | 1902404320
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Entity Type | Individual
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Provider Name | SHANELLE LYNETTE RAIFORD DNP
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Gender | Female
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Dates
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Enumeration Date | 10/16/2020
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Last Update Date | 01/14/2025
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Provider Practice Location Address
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Address Line | 1133 EAGLES LANDING PKWY
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-5085
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Country | US
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Telephone | 678-604-1053
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Fax |
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Provider Business Mailing Address
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Address Line | 2028 HIDDEN MEADOW LN
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City | STONE MOUNTAIN
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State | GA
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Zip | 30088-4448
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | RN245806
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License Number State | GA
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