Provider Demographics
NPI:1629041355
Name:HARRELL, SHIRLEY LAVON (NP)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:LAVON
Last Name:HARRELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:LAVON
Other - Last Name:KNOWLES HARRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 1227
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534-1227
Mailing Address - Country:US
Mailing Address - Phone:912-384-1900
Mailing Address - Fax:912-389-2112
Practice Address - Street 1:1101 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2207
Practice Address - Country:US
Practice Address - Phone:912-384-1900
Practice Address - Fax:912-389-2112
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN056220163WE0003X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA804987669AMedicaid
GA804987669BMedicaid
GA804987669BMedicaid
GAQ57052Medicare UPIN