Provider Demographics
NPI:1699216259
Name:GULLATT, SHAMEKA
Entity Type:Individual
Prefix:
First Name:SHAMEKA
Middle Name:
Last Name:GULLATT
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 1:4749 NELSON BROGDON BLVD
Mailing Address - Street 2:BLD 100 SUITE 4
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-7513
Mailing Address - Country:US
Mailing Address - Phone:470-769-0054
Mailing Address - Fax:
Practice Address - Street 1:4749 NELSON BROGDON BLVD
Practice Address - Street 2:BLD 100 SUITE 4
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-7513
Practice Address - Country:US
Practice Address - Phone:470-769-0054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT001306173C00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist