Provider Demographics
NPI:1811911407
Name:BREEDLOVE, SHIRLEY RENE (FNP)
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:RENE
Last Name:BREEDLOVE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:RENE
Other - Middle Name:RICHARDSON
Other - Last Name:BREEDLOVE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:1244 HISTORIC HOMER HWY
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:GA
Mailing Address - Zip Code:30547-2737
Mailing Address - Country:US
Mailing Address - Phone:706-677-2250
Mailing Address - Fax:706-677-4208
Practice Address - Street 1:1244 HISTORIC HOMER HWY
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:GA
Practice Address - Zip Code:30547-2737
Practice Address - Country:US
Practice Address - Phone:706-677-2250
Practice Address - Fax:706-677-4208
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN135396363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000910247CMedicaid
GA50BBFGVMedicare PIN
P35183Medicare UPIN