MEDICARE: DR. SHANINA TRALICE LASSITER DFM, DTN, PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171400000X	Health & Wellness Coach
2	175F00000X	Naturopath

General Provider Information

NPI Number	:	1023760105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANINA TRALICE LASSITER DFM, DTN, PH.D

Provider Business Mailing Address
First Line	:	6111 PEACHTREE DUNWOODY RD STE E101
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-4513
Country	:	US
Telephone Number	:	678-561-4522
Fax Number	:	678-561-1297

Provider Business Practice Location Address
First Line	:	6111 PEACHTREE DUNWOODY RD STE E101
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-4513
Country	:	US
Telephone Number	:	678-561-4522
Fax Number	:	678-561-1297

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2022
Last Update Date	:	11/11/2022

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