Provider Demographics
NPI:1740711308
Name:HEATH, JANEANNA SHELL (MD)
Entity type:Individual
Prefix:
First Name:JANEANNA
Middle Name:SHELL
Last Name:HEATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 HAWTHORNE PARK
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2151
Mailing Address - Country:US
Mailing Address - Phone:706-613-6136
Mailing Address - Fax:
Practice Address - Street 1:225 HAWTHORNE PARK
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2151
Practice Address - Country:US
Practice Address - Phone:706-613-6136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA89465208000000X
MST-3429208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003254040BMedicaid