Provider Demographics
NPI:1932348745
Name:PHILLIPS, SHANON RENEE (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANON
Middle Name:RENEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CPNP
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Mailing Address - Street 1:5040 BILL GARDNER PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-3757
Mailing Address - Country:US
Mailing Address - Phone:678-583-5437
Mailing Address - Fax:678-583-5484
Practice Address - Street 1:5040 BILL GARDNER PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-3757
Practice Address - Country:US
Practice Address - Phone:678-583-5437
Practice Address - Fax:678-583-5484
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2013-12-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARN169956363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner