Healthcare Provider Details

I. General information

NPI: 1588018261
Provider Name (Legal Business Name): SHANNON MAY GREENE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 UNIVERSITY AVE
COLUMBUS GA
31907-5679
US

IV. Provider business mailing address

3515 GENTIAN BLVD APT 9
COLUMBUS GA
31907-8832
US

V. Phone/Fax

Practice location:
  • Phone: 706-565-4332
  • Fax:
Mailing address:
  • Phone: 407-591-6034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT002549
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL3824
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: