Provider Demographics
NPI:1336793710
Name:THURMOND, SHANICE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANICE
Middle Name:
Last Name:THURMOND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6558 ROSWELL RD APT 1168
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5071
Mailing Address - Country:US
Mailing Address - Phone:414-698-9920
Mailing Address - Fax:
Practice Address - Street 1:2201 TALMADGE RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-1608
Practice Address - Country:US
Practice Address - Phone:404-564-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA9934207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program