Provider Demographics
NPI:1508405952
Name:WILLIAMS, SHANNON (LDO)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7306 STATE HIGHWAY 21 # 268
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-9274
Mailing Address - Country:US
Mailing Address - Phone:912-373-6797
Mailing Address - Fax:
Practice Address - Street 1:34 BIRCH CIR
Practice Address - Street 2:
Practice Address - City:PORT WENTWORTH
Practice Address - State:GA
Practice Address - Zip Code:31407-3376
Practice Address - Country:US
Practice Address - Phone:912-650-1161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002432156FC0800X, 156FX1800X
SC615156FC0800X
SC1233156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Single Specialty