Healthcare Provider Details

I. General information

NPI: 1467958678
Provider Name (Legal Business Name): SHANNON NISHA DELLEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON N GREENBERG

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1447 HARPER ST STE 4G
AUGUSTA GA
30912-0020
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-3672
  • Fax:
Mailing address:
  • Phone: 706-721-3672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number103463
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01089536A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: