Basic Information
| Provider Information | |||||||||
| NPI: | 1396711834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSLEE | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | WILSON | ||||||||
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| Credential: | MPA, MSED, ATC, PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | LEA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 51 DRIFTSTONE CIR | ||||||||
| Address2: | |||||||||
| City: | ARDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287049140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432437298 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1305 JENNINGS MILL RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | WATKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306777241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066135880 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 0126000585 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363AM0700X | 0110003302 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 0010-03506 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 10732 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.