Basic Information
| Provider Information | |||||||||
| NPI: | 1134570336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODING | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | JACKSON | ||||||||
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| Credential: | MSN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3710 LANDMARK DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038981470 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2016 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5010159 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | 20509 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1134570336 | 05 | NC | MEDICAID | NP4540 | 05 | SC | MEDICAID | 1134570336 | 05 | SC | MEDICAID |