Provider Demographics
NPI:1457486425
Name:SHOCKLEY, NAIOMI MICHELLE (CPNP)
Entity Type:Individual
Prefix:MS
First Name:NAIOMI
Middle Name:MICHELLE
Last Name:SHOCKLEY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1115 MOUNT ZION RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2266
Mailing Address - Country:US
Mailing Address - Phone:770-960-9999
Mailing Address - Fax:770-960-0931
Practice Address - Street 1:1115 MOUNT ZION RD STE E
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2266
Practice Address - Country:US
Practice Address - Phone:770-960-9999
Practice Address - Fax:770-960-0931
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN159492363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20060526OtherPEDS NURSING CERTIFICATIO
GA472261189OtherTAX ID
GA581238651OtherTAX ID #
GANCO000006OtherNATIONAL BD OF PED NURSE
GARN159492OtherLICENSE #
GA003134388BMedicaid