Provider Demographics
NPI:1003218520
Name:SHUPE, LEAH (PAC)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:SHUPE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 COGBURN AVE NW STE 250
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1056
Mailing Address - Country:US
Mailing Address - Phone:770-422-5557
Mailing Address - Fax:770-422-8816
Practice Address - Street 1:2045 HIGHWAY 34 E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1327
Practice Address - Country:US
Practice Address - Phone:770-502-0202
Practice Address - Fax:770-502-8822
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN214000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily