Provider Demographics
NPI:1215336656
Name:HOLMES, SHANNON (CNA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HOLMES
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 STONEBRIDGE PARK CIR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-9047
Mailing Address - Country:US
Mailing Address - Phone:404-477-8609
Mailing Address - Fax:
Practice Address - Street 1:739 STONEBRIDGE PARK CIR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-9047
Practice Address - Country:US
Practice Address - Phone:404-477-8609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0030031849376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide