Healthcare Provider Details

I. General information

NPI: 1801224746
Provider Name (Legal Business Name): SHANNON J DIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2013
Last Update Date: 10/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8323 DUNWOODY PL
ATLANTA GA
30350-3307
US

IV. Provider business mailing address

8323 DUNWOODY PL
ATLANTA GA
30350-3307
US

V. Phone/Fax

Practice location:
  • Phone: 770-642-6003
  • Fax:
Mailing address:
  • Phone: 770-642-6003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCOSA029717
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: