Provider Demographics
NPI:1790354173
Name:AMOS, SHELLEY (NP)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:AMOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1899 LAKE RD STE 212
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2293
Mailing Address - Country:US
Mailing Address - Phone:770-222-5488
Mailing Address - Fax:
Practice Address - Street 1:1899 LAKE RD STE 212
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2293
Practice Address - Country:US
Practice Address - Phone:770-222-5488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN276693363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily