Provider Demographics
NPI:1245740745
Name:STAFFORD, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3206 FALLIGANT AVE
Mailing Address - Street 2:
Mailing Address - City:THUNDERBOLT
Mailing Address - State:GA
Mailing Address - Zip Code:31404-5314
Mailing Address - Country:US
Mailing Address - Phone:912-660-4484
Mailing Address - Fax:
Practice Address - Street 1:8408 MARCUS PL STE A
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4928
Practice Address - Country:US
Practice Address - Phone:912-660-4484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty