Provider Demographics
NPI:1396711834
Name:HENSLEE, SHANNON WILSON (MPA, MSED, ATC, PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:WILSON
Last Name:HENSLEE
Suffix:
Gender:F
Credentials:MPA, MSED, ATC, PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEA
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:51 DRIFTSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-9140
Mailing Address - Country:US
Mailing Address - Phone:443-243-7298
Mailing Address - Fax:
Practice Address - Street 1:1305 JENNINGS MILL RD STE 110
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7241
Practice Address - Country:US
Practice Address - Phone:706-613-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260005852255A2300X
VA0110003302363AM0700X
NC0010-03506363AM0700X
GA10732363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer