Provider Demographics
NPI:1750627105
Name:MAYFIELD, SHANNON (CNM)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MAYFIELD
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9069
Mailing Address - Country:US
Mailing Address - Phone:770-538-1723
Mailing Address - Fax:470-202-9820
Practice Address - Street 1:290 COUNTRY CLUB DR STE 210
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9022
Practice Address - Country:US
Practice Address - Phone:770-538-1723
Practice Address - Fax:470-202-9820
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN159998176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003129843BMedicaid