Provider Demographics
NPI:1588018261
Name:GREENE, SHANNON MAY (ATC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MAY
Last Name:GREENE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 GENTIAN BLVD APT 9
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-8832
Mailing Address - Country:US
Mailing Address - Phone:407-591-6034
Mailing Address - Fax:
Practice Address - Street 1:4225 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-5679
Practice Address - Country:US
Practice Address - Phone:706-565-4332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0025492255A2300X
FLAL38242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer