Provider Demographics
NPI:1336011295
Name:GOTTIPAMULA, SHIVANI
Entity type:Individual
Prefix:
First Name:SHIVANI
Middle Name:
Last Name:GOTTIPAMULA
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 1:5455 SCENIC VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-5482
Mailing Address - Country:US
Mailing Address - Phone:919-656-5655
Mailing Address - Fax:
Practice Address - Street 1:5455 SCENIC VALLEY DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-5482
Practice Address - Country:US
Practice Address - Phone:919-656-5655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-20
Last Update Date:2025-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN340008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily