Provider Demographics
NPI:1265303804
Name:HENRY, SHANDA DANIELLE (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:SHANDA
Middle Name:DANIELLE
Last Name:HENRY
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:SHANDA
Other - Middle Name:DANIELLE
Other - Last Name:CALLENBACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,LAT, ATC
Mailing Address - Street 1:82 SAND PUMP LN
Mailing Address - Street 2:
Mailing Address - City:LAKEMONT
Mailing Address - State:GA
Mailing Address - Zip Code:30552-2921
Mailing Address - Country:US
Mailing Address - Phone:706-490-1430
Mailing Address - Fax:
Practice Address - Street 1:230 WILDCAT TRAIL
Practice Address - Street 2:
Practice Address - City:TIGER
Practice Address - State:GA
Practice Address - Zip Code:30576
Practice Address - Country:US
Practice Address - Phone:706-490-1430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT002799207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine