Provider Demographics
NPI:1982377271
Name:SMITH, SHANTA MONTRAILE (CNA)
Entity Type:Individual
Prefix:
First Name:SHANTA
Middle Name:MONTRAILE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4220
Mailing Address - Country:US
Mailing Address - Phone:678-702-4639
Mailing Address - Fax:678-692-8131
Practice Address - Street 1:121 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4220
Practice Address - Country:US
Practice Address - Phone:678-702-4639
Practice Address - Fax:678-692-8131
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-01
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 253Z00000X, 343900000X
GAPCH008442311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)