Provider Demographics
NPI:1205229531
Name:AUSBORN, SHANITA SOUTHERLAND (APRN)
Entity Type:Individual
Prefix:
First Name:SHANITA
Middle Name:SOUTHERLAND
Last Name:AUSBORN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7307
Mailing Address - Country:US
Mailing Address - Phone:478-787-4266
Mailing Address - Fax:478-787-4199
Practice Address - Street 1:770 WALNUT ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7307
Practice Address - Country:US
Practice Address - Phone:478-787-4266
Practice Address - Fax:478-787-4199
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN203226363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily