Healthcare Provider Details

I. General information

NPI: 1619242922
Provider Name (Legal Business Name): SHANNON LOTUS ASHLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 HIGHWAY 54 W SUITE 150
PEACHTREE CITY GA
30269-4794
US

IV. Provider business mailing address

PO BOX 102321
ATLANTA GA
30368-2321
US

V. Phone/Fax

Practice location:
  • Phone: 770-486-5000
  • Fax: 404-588-2624
Mailing address:
  • Phone: 770-801-2500
  • Fax: 770-803-2121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number074710
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: