MEDICARE: SHANTORIUS SHANTAE STACKS FNP

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	363LF0000X	Family Nurse Practitioner	APRN-NP256370	GA

General Provider Information

NPI Number	:	1790489961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTORIUS SHANTAE STACKS FNP

Provider Business Mailing Address
First Line	:	2219 BENIDORM CT
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-8497
Country	:	US
Telephone Number	:	770-572-7109
Fax Number	:

Provider Business Practice Location Address
First Line	:	2219 BENIDORM CT
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-8497
Country	:	US
Telephone Number	:	770-572-7109
Fax Number	:

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

Provider Enumeration Date	:	03/29/2023
Last Update Date	:	10/29/2025

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