Provider Demographics
NPI:1699590224
Name:WEAVER, SHANTONIA MARIA (MLS)
Entity type:Individual
Prefix:MS
First Name:SHANTONIA
Middle Name:MARIA
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3721 SALEM CHAPEL DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4837
Mailing Address - Country:US
Mailing Address - Phone:678-979-6538
Mailing Address - Fax:
Practice Address - Street 1:11935 ABERCORN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1918
Practice Address - Country:US
Practice Address - Phone:912-478-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA246QM0706X, 390200000X
246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program