Basic Information
| Provider Information | |||||||||
| NPI: | 1558991711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHORTER | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | SOLAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967033 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 N SUMTER ST | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291504972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037749797 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2020 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 23606 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | NP6592 | 05 | SC | MEDICAID |