Provider Demographics
NPI:1376304253
Name:GEORGE, SHAWNTEL RENEE
Entity Type:Individual
Prefix:
First Name:SHAWNTEL
Middle Name:RENEE
Last Name:GEORGE
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 1:207 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3409
Mailing Address - Country:US
Mailing Address - Phone:919-478-6276
Mailing Address - Fax:
Practice Address - Street 1:207 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3409
Practice Address - Country:US
Practice Address - Phone:919-478-6276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21022225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist