Provider Demographics
NPI:1417841560
Name:MCKINNEY, SHANTA L
Entity type:Individual
Prefix:
First Name:SHANTA
Middle Name:L
Last Name:MCKINNEY
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 1:2854 PLEASANT OAK DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-8081
Mailing Address - Country:US
Mailing Address - Phone:678-835-8170
Mailing Address - Fax:
Practice Address - Street 1:3460 SUMMIT RIDGE PKWY STE 402
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1621
Practice Address - Country:US
Practice Address - Phone:470-760-8998
Practice Address - Fax:678-866-6909
Is Sole Proprietor?:No
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAL5D7K9M2246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy