Provider Demographics
NPI:1083879621
Name:ROBERTS, SHAWANICA L (DC)
Entity Type:Individual
Prefix:
First Name:SHAWANICA
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DC
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 672842
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30006-0048
Mailing Address - Country:US
Mailing Address - Phone:770-795-0506
Mailing Address - Fax:
Practice Address - Street 1:6254 MEMORIAL DR STE F
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-2884
Practice Address - Country:US
Practice Address - Phone:770-795-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008151111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACHIR008151OtherLICENSE NUMBER