Healthcare Provider Details

I. General information

NPI: 1093678062
Provider Name (Legal Business Name): SHANNON BRAVO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2025
Last Update Date: 12/06/2025
Certification Date: 12/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4443 GA HIGHWAY 219
FORTSON GA
31808-4523
US

IV. Provider business mailing address

3821 GRAY FOX DR
COLUMBUS GA
31909-3203
US

V. Phone/Fax

Practice location:
  • Phone: 706-810-0440
  • Fax:
Mailing address:
  • Phone: 862-432-1399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1452515
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: