Provider Demographics
NPI:1588135305
Name:KOEHLER, SHANA BAILEY (LDO)
Entity type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:BAILEY
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:LEIGH
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LDO
Mailing Address - Street 1:2124 HIGH FALLS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-5368
Mailing Address - Country:US
Mailing Address - Phone:706-741-2609
Mailing Address - Fax:
Practice Address - Street 1:135 WILLOW LN
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6574
Practice Address - Country:US
Practice Address - Phone:678-432-3039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA191721156FC0800X
GALDO002616156FX1800X, 156FC0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALDO002616OtherGEORGIA BOARD OF DISPENSING OPTICIANS