Provider Demographics
NPI:1255808515
Name:KING, SHONDA (TRICHOLOGY)
Entity type:Individual
Prefix:
First Name:SHONDA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:TRICHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 641
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:GA
Mailing Address - Zip Code:31320-0641
Mailing Address - Country:US
Mailing Address - Phone:912-463-2883
Mailing Address - Fax:
Practice Address - Street 1:150 BUTLER ST STE D5-D7
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:GA
Practice Address - Zip Code:31320-4575
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center