Provider Demographics
NPI:1821496241
Name:HEALTHY STAGES PEDIATRICS
Entity Type:Organization
Organization Name:HEALTHY STAGES PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NAIOMI
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHOCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:770-960-9999
Mailing Address - Street 1:1115 MOUNT ZION RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2266
Mailing Address - Country:US
Mailing Address - Phone:770-960-9999
Mailing Address - Fax:770-960-0931
Practice Address - Street 1:1115 MOUNT ZION RD
Practice Address - Street 2:SUITE E
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2266
Practice Address - Country:US
Practice Address - Phone:770-960-9999
Practice Address - Fax:770-960-0931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN159492363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty