Provider Demographics
NPI:1215176607
Name:BEAULIEU, SHANNON M
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:M
Last Name:BEAULIEU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1676 MULKEY RD
Mailing Address - Street 2:STE A
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1170
Mailing Address - Country:US
Mailing Address - Phone:678-838-6600
Mailing Address - Fax:
Practice Address - Street 1:1676 MULKEY RD
Practice Address - Street 2:STE A
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1170
Practice Address - Country:US
Practice Address - Phone:678-838-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist