Provider Demographics
NPI:1790489961
Name:STACKS, SHANTORIUS SHANTAE (FNP)
Entity Type:Individual
Prefix:
First Name:SHANTORIUS
Middle Name:SHANTAE
Last Name:STACKS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 BENIDORM CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-8497
Mailing Address - Country:US
Mailing Address - Phone:770-572-7109
Mailing Address - Fax:
Practice Address - Street 1:2219 BENIDORM CT
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-8497
Practice Address - Country:US
Practice Address - Phone:770-572-7109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN256370363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily