Provider Demographics
NPI:1063762870
Name:PATTERSON, SHONTIAYA S (FNP)
Entity type:Individual
Prefix:
First Name:SHONTIAYA
Middle Name:S
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 WATKINS GLEN DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-4061
Mailing Address - Country:US
Mailing Address - Phone:770-309-8302
Mailing Address - Fax:
Practice Address - Street 1:1324 HIGHWAY 138 SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-1404
Practice Address - Country:US
Practice Address - Phone:770-907-4949
Practice Address - Fax:770-907-4022
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN219785101YM0800X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health