Provider Demographics
NPI:1447130075
Name:REAL, SHANA SMITH
Entity type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:SMITH
Last Name:REAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:BERNETTA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:255 STONEWALL AVE W APT 2
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 STONEWALL AVE W APT 2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1522
Practice Address - Country:US
Practice Address - Phone:859-251-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN274577390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program