Healthcare Provider Details

I. General information

NPI: 1457166183
Provider Name (Legal Business Name): SHANNON GOWLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12540 BROADWELL RD STE 1101
MILTON GA
30004-6405
US

IV. Provider business mailing address

225 PARKWAY 575 UNIT 1609
WOODSTOCK GA
30188-1513
US

V. Phone/Fax

Practice location:
  • Phone: 404-895-1302
  • Fax:
Mailing address:
  • Phone: 404-895-1302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: