Provider Demographics
NPI:1609218601
Name:DELOACH, SHANA B (CNM)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:B
Last Name:DELOACH
Suffix:
Gender:
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 KING AVENUE STE 120
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:706-475-5700
Mailing Address - Fax:
Practice Address - Street 1:242 KING AVENUE STE 120
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-475-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN216236207V00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003142037LMedicaid
GA04702359OtherAMERIGROUP
GA003142037KMedicaid
GA003142037JMedicaid
GA003142037MMedicaid
GA1368524OtherWELLCARE
GA003142037OMedicaid
GA003142037NMedicaid