Healthcare Provider Details

I. General information

NPI: 1881255511
Provider Name (Legal Business Name): SHANNON ASHE SHOCKLEY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 WHITE CIR STE 105
MARIETTA GA
30066-5836
US

IV. Provider business mailing address

1810 WHITE CIR STE 105
MARIETTA GA
30066-5836
US

V. Phone/Fax

Practice location:
  • Phone: 678-797-6820
  • Fax: 770-424-8787
Mailing address:
  • Phone: 678-797-6820
  • Fax: 770-424-8787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN171136
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: