Provider Demographics
NPI:1841534617
Name:WOMACK, SHANNON (LPN)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:WOMACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1877
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-7242
Mailing Address - Country:US
Mailing Address - Phone:470-778-1148
Mailing Address - Fax:
Practice Address - Street 1:1775 PARKER RD SE STE 200
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6654
Practice Address - Country:US
Practice Address - Phone:470-778-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
GALPN062876164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No251E00000XAgenciesHome Health