Provider Demographics
NPI:1417302761
Name:SHUMAN MACK, VERONDA TRYLAC (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:
First Name:VERONDA
Middle Name:TRYLAC
Last Name:SHUMAN MACK
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15106 KENSINGTON TRCE
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3274
Mailing Address - Country:US
Mailing Address - Phone:786-312-0975
Mailing Address - Fax:
Practice Address - Street 1:7494 COVINGTON HWY
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-7612
Practice Address - Country:US
Practice Address - Phone:786-312-0975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-24
Last Update Date:2016-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management