Provider Demographics
NPI:1801259718
Name:HART, SHANNON (RN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 813683
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30081-8683
Mailing Address - Country:US
Mailing Address - Phone:770-874-3238
Mailing Address - Fax:770-874-3239
Practice Address - Street 1:1264 CONCORD RD SE
Practice Address - Street 2:106
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-5302
Practice Address - Country:US
Practice Address - Phone:770-874-3238
Practice Address - Fax:770-874-3239
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN226101163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse