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General NPI Number Information
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NPI Number | 1508405952
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Entity Type | Individual
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Provider Name | SHANNON WILLIAMS LDO
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Gender | Female
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Dates
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Enumeration Date | 01/02/2020
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Last Update Date | 01/02/2020
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Provider Practice Location Address
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Address Line | 34 BIRCH CIR
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City | PORT WENTWORTH
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State | GA
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Zip | 31407-3376
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Country | US
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Telephone | 912-650-1161
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Fax |
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Provider Business Mailing Address
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Address Line | 7306 STATE HIGHWAY 21 # 268
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City | PORT WENTWORTH
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State | GA
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Zip | 31407-9274
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Country | US
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Telephone | 912-373-6797
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FC0800X
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Taxonomy Name | Contact Lens Technician/Technologist
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License Number | LDO002432
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 156FC0800X
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Taxonomy Name | Contact Lens Technician/Technologist
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License Number | 615
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 1233
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License Number State | SC
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Taxonomy #4
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | LDO002432
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License Number State | GA
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