MEDICARE: SHANEA R MCDANIEL RN, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN198807	GA

General Provider Information

NPI Number	:	1043991250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANEA R MCDANIEL RN, PMHNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 782
Second Line	:
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281-0782
Country	:	US
Telephone Number	:	803-295-2508
Fax Number	:

Provider Business Practice Location Address
First Line	:	552 CREEK VALLEY CT
Second Line	:
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281-7901
Country	:	US
Telephone Number	:	803-617-9953
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2023
Last Update Date	:	07/31/2023

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