Provider Demographics
NPI:1588703565
Name:HARTLEY, SHANDA T (FNP)
Entity type:Individual
Prefix:MRS
First Name:SHANDA
Middle Name:T
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:FNP
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Other - Credentials:
Mailing Address - Street 1:207 CRESTMONT WAY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8875
Mailing Address - Country:US
Mailing Address - Phone:678-493-7374
Mailing Address - Fax:
Practice Address - Street 1:207 CRESTMONT WAY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8875
Practice Address - Country:US
Practice Address - Phone:678-880-6698
Practice Address - Fax:470-299-9936
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN174554 NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I502987Medicare Oscar/Certification