Healthcare Provider Details

I. General information

NPI: 1679137467
Provider Name (Legal Business Name): SHANNON SUAREZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5730 GLENRIDGE DR STE 200
ATLANTA GA
30328-5579
US

IV. Provider business mailing address

1930 BRANNAN RD
MCDONOUGH GA
30253-4310
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-5206
  • Fax:
Mailing address:
  • Phone: 678-284-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN11000487
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN283116
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: