Provider Demographics
NPI:1447245345
Name:MCMILLAN, SHALESE ANTOINETTE (PLD)
Entity Type:Individual
Prefix:MISS
First Name:SHALESE
Middle Name:ANTOINETTE
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:PLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 PARKWAY N
Mailing Address - Street 2:APT.817
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1555
Mailing Address - Country:US
Mailing Address - Phone:678-423-7405
Mailing Address - Fax:
Practice Address - Street 1:137 JACKSON ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1572
Practice Address - Country:US
Practice Address - Phone:770-254-7400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education