Provider Demographics
NPI:1851933303
Name:STALLWORTH, SHANEA MONIQUE
Entity Type:Individual
Prefix:
First Name:SHANEA
Middle Name:MONIQUE
Last Name:STALLWORTH
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 1:517 WALLIS FARM LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-5465
Mailing Address - Country:US
Mailing Address - Phone:850-485-8244
Mailing Address - Fax:
Practice Address - Street 1:517 WALLIS FARM LN
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-5465
Practice Address - Country:US
Practice Address - Phone:850-485-8244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN223742163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine