Basic Information
| Provider Information | |||||||||
| NPI: | 1336148188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORTER | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP-C, NNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 980 JOHNSON FY RD NE STE 620 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042529751 | ||||||||
| FaxNumber: | 6789905763 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 JOHNSON FY RD NE STE 620 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042529751 | ||||||||
| FaxNumber: | 6789905763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN139907 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LN0000X | RN139907 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
| ID | Type | State | Issuer | Description | 713532283B | 05 | GA | MEDICAID | 713532283C | 05 | GA | MEDICAID | 713532283A | 05 | GA | MEDICAID |