Provider Demographics
NPI:1295563278
Name:WADE, SHANTA (APRN)
Entity type:Individual
Prefix:MRS
First Name:SHANTA
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 S 8TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:770-233-4824
Practice Address - Street 1:619 S 8TH ST STE 100
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4260
Practice Address - Country:US
Practice Address - Phone:678-248-2899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN261484363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily