Provider Demographics
NPI:1003578840
Name:JOHN, SHERLY
Entity Type:Individual
Prefix:MRS
First Name:SHERLY
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 HINTON FARM WAY
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2175
Mailing Address - Country:US
Mailing Address - Phone:678-800-6651
Mailing Address - Fax:
Practice Address - Street 1:4958 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-4148
Practice Address - Country:US
Practice Address - Phone:404-809-2408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAG08210123363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health