Provider Demographics
NPI:1730840083
Name:SHANNON, SHANICE (PA)
Entity type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 HOSPITAL DR STE 100A
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9076
Mailing Address - Country:US
Mailing Address - Phone:770-474-7416
Mailing Address - Fax:
Practice Address - Street 1:1101 HOSPITAL DR STE 100A
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9076
Practice Address - Country:US
Practice Address - Phone:770-474-7416
Practice Address - Fax:770-692-0761
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2025-03-26
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant