Provider Demographics
NPI:1073611059
Name:YOUNGBLOOD, SHIRLEY (NP)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 409
Mailing Address - Street 2:
Mailing Address - City:HIAWASSEE
Mailing Address - State:GA
Mailing Address - Zip Code:30546-0409
Mailing Address - Country:US
Mailing Address - Phone:706-896-2289
Mailing Address - Fax:706-896-6007
Practice Address - Street 1:56 HOSPITAL STREET
Practice Address - Street 2:
Practice Address - City:HIAWASSEE
Practice Address - State:GA
Practice Address - Zip Code:30546
Practice Address - Country:US
Practice Address - Phone:706-896-2289
Practice Address - Fax:706-896-6007
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN053003363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003727OtherMEDICAID
GA50BBHBHMedicare ID - Type Unspecified
P24297Medicare UPIN