1720074339 NPI number — GLENN CLINTON SHEDD FNP

Table of content: GLENN CLINTON SHEDD FNP (NPI 1720074339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720074339 NPI number — GLENN CLINTON SHEDD FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEDD
Provider First Name:
GLENN
Provider Middle Name:
CLINTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720074339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603725
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-3725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-575-2625
Provider Business Mailing Address Fax Number:
828-350-2174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 HAWTHORNE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30606-2152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-613-8500
Provider Business Practice Location Address Fax Number:
706-613-8844
Provider Enumeration Date:
09/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  RN117525 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 202I507833 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000804427B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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