Provider Demographics
NPI:1609218601
Name:DELOACH, SHANA B (CNM, FNP)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:B
Last Name:DELOACH
Suffix:
Gender:F
Credentials:CNM, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-297-2200
Mailing Address - Fax:770-534-8139
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-297-2200
Practice Address - Fax:770-534-8139
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN216236363LF0000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003142037LMedicaid
GA04702359OtherAMERIGROUP
GA003142037NMedicaid
GA1368524OtherWELLCARE
GA003142037KMedicaid
GA003142037MMedicaid
GA003142037OMedicaid
GA003142037JMedicaid