Provider Demographics
NPI:1851170542
Name:MATHIS-MCWHORTER, SHANTA
Entity Type:Individual
Prefix:
First Name:SHANTA
Middle Name:
Last Name:MATHIS-MCWHORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANTA
Other - Middle Name:MATHIS
Other - Last Name:MCWHORTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1010 HOPE LN
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-4313
Mailing Address - Country:US
Mailing Address - Phone:706-816-6018
Mailing Address - Fax:
Practice Address - Street 1:1010 HOPE LN
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-4313
Practice Address - Country:US
Practice Address - Phone:706-816-6018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN208865363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health