Provider Demographics
NPI:1679138655
Name:DICKEY, SHANTELISE MONIQUE (DNP, CPNP-PC)
Entity type:Individual
Prefix:DR
First Name:SHANTELISE
Middle Name:MONIQUE
Last Name:DICKEY
Suffix:
Gender:F
Credentials:DNP, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HOWELL ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-5402
Mailing Address - Country:US
Mailing Address - Phone:706-975-8662
Mailing Address - Fax:706-646-5069
Practice Address - Street 1:300 HOWELL ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-5402
Practice Address - Country:US
Practice Address - Phone:706-975-8662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN199300363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics