Individual
CHAUNTA WADE SHANNON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1090 EAGLES BROOKE DR, LOCUST GROVE, GA 30248-2475
(419) 610-3721
Mailing address
1090 EAGLES BROOKE DR, LOCUST GROVE, GA 30248-2475
(419) 610-3721
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
325286
MS
Other
Enumeration date
03/28/2024
Last updated
03/28/2024
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