Provider Demographics
NPI:1144053026
Name:FALLEN, SHANTELL
Entity type:Individual
Prefix:
First Name:SHANTELL
Middle Name:
Last Name:FALLEN
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 1:414 LADY GUINEVERE WAY
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1720
Mailing Address - Country:US
Mailing Address - Phone:678-789-7663
Mailing Address - Fax:
Practice Address - Street 1:448 FREEDOM RD
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AL
Practice Address - Zip Code:36040-4419
Practice Address - Country:US
Practice Address - Phone:678-789-7663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-24
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL172V00000X, 3747P1801X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant