Provider Demographics
NPI:1518598929
Name:HARRIS, SHIRLEY R
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:R
Last Name:HARRIS
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 1:1222 LUKE STATION RD
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-6010
Mailing Address - Country:US
Mailing Address - Phone:229-308-0598
Mailing Address - Fax:
Practice Address - Street 1:1222 LUKE STATION RD
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-6010
Practice Address - Country:US
Practice Address - Phone:229-308-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider