Provider Demographics
NPI:1336148188
Name:SHORTER, BRENDA (NP-C, NNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:SHORTER
Suffix:
Gender:F
Credentials:NP-C, NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 JOHNSON FY RD NE STE 620
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1608
Mailing Address - Country:US
Mailing Address - Phone:404-252-9751
Mailing Address - Fax:678-990-5763
Practice Address - Street 1:980 JOHNSON FY RD NE STE 620
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-252-9751
Practice Address - Fax:678-990-5763
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN139907363LF0000X, 363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA713532283BMedicaid
GA713532283CMedicaid
GA713532283AMedicaid