Provider Demographics
NPI:1245100353
Name:BEN-SHIDAH, TIMESHA
Entity type:Individual
Prefix:
First Name:TIMESHA
Middle Name:
Last Name:BEN-SHIDAH
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 1:529 AZALEA BLOOM DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5739
Mailing Address - Country:US
Mailing Address - Phone:404-271-7525
Mailing Address - Fax:
Practice Address - Street 1:529 AZALEA BLOOM DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-5739
Practice Address - Country:US
Practice Address - Phone:404-271-7525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-05
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANP282511363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily