Provider Demographics
NPI:1215675806
Name:SHANKS, NYLAH
Entity type:Individual
Prefix:
First Name:NYLAH
Middle Name:
Last Name:SHANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 JOSEPH E BOONE BLVD NW APT D103
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30314-2037
Mailing Address - Country:US
Mailing Address - Phone:773-587-7716
Mailing Address - Fax:
Practice Address - Street 1:35 COLLIER RD NW STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1780
Practice Address - Country:US
Practice Address - Phone:404-350-9772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC060574183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician