Provider Demographics
NPI:1255785366
Name:INCI, SHANNON ASHLEY (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ASHLEY
Last Name:INCI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 GREYSTONE POWER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-8297
Mailing Address - Country:US
Mailing Address - Phone:678-945-8345
Mailing Address - Fax:470-956-1180
Practice Address - Street 1:120 GREYSTONE POWER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-8297
Practice Address - Country:US
Practice Address - Phone:678-945-8345
Practice Address - Fax:770-956-1180
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8305207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty