Provider Demographics
NPI:1225746191
Name:METELLUS, SHANEQUE
Entity Type:Individual
Prefix:
First Name:SHANEQUE
Middle Name:
Last Name:METELLUS
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 1:1850 CHARDIN WAY
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-2141
Mailing Address - Country:US
Mailing Address - Phone:678-704-9503
Mailing Address - Fax:
Practice Address - Street 1:1850 CHARDIN WAY
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-2141
Practice Address - Country:US
Practice Address - Phone:678-704-9503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management