Provider Demographics
NPI:1225450729
Name:MARSHALL, SHAWANDA LATRECE (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:SHAWANDA
Middle Name:LATRECE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:SHAWANDA
Other - Middle Name:LATRECE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1825 MARTHA BERRY BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1625
Mailing Address - Country:US
Mailing Address - Phone:706-295-5331
Mailing Address - Fax:
Practice Address - Street 1:330 TURNER MCCALL BLVD SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5630
Practice Address - Country:US
Practice Address - Phone:706-291-1754
Practice Address - Fax:706-378-2455
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN199472363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner