Provider Demographics
NPI:1346219680
Name:BETSILL, SHANNON WOODALL (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:WOODALL
Last Name:BETSILL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:BETSILL-ROOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 740209
Mailing Address - Street 2:DEPT. 1029
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0209
Mailing Address - Country:US
Mailing Address - Phone:941-360-1566
Mailing Address - Fax:941-358-9818
Practice Address - Street 1:2500 HOSPITAL BLVD
Practice Address - Street 2:SUITE 480
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:678-762-0676
Practice Address - Fax:678-762-7980
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN111983367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000776685Medicaid
GA000776685Medicaid