MEDICARE: DR. SHANNON DONELL NELSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	062400	GA

General Provider Information

NPI Number	:	1669696829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON DONELL NELSON MD

Provider Business Mailing Address
First Line	:	939 BOB ARNOLD BLVD
Second Line	:	STE F
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-3258
Country	:	US
Telephone Number	:	770-739-2440
Fax Number	:	770-819-8808

Provider Business Practice Location Address
First Line	:	939 BOB ARNOLD BLVD
Second Line	:	STE F
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-3258
Country	:	US
Telephone Number	:	770-739-2440
Fax Number	:	770-819-8808

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	12/11/2016

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