Provider Demographics
NPI:1689203952
Name:BYRD, SHIRLEY ANN
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANN
Last Name:BYRD
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 1:45 LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-3612
Mailing Address - Country:US
Mailing Address - Phone:912-484-7573
Mailing Address - Fax:
Practice Address - Street 1:45 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31407-3612
Practice Address - Country:US
Practice Address - Phone:912-484-7573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA385HR2060X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child