Provider Demographics
NPI:1437914892
Name:GONZALEZ, SHANNON (LAC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 ARGONNE AVE NE APT 1
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2078
Mailing Address - Country:US
Mailing Address - Phone:239-292-8914
Mailing Address - Fax:
Practice Address - Street 1:502 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3533
Practice Address - Country:US
Practice Address - Phone:239-292-8914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA420171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist