| Doctor Name: | MRS. SHANNON SLOCUMB ETHRIDGE |
| NPI Number: | 1033527254 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | NP-C |
| License Number: | RN198355 |
| Business Practice Address: | 555 Bluebird Blvd Fort Valley, GA - 310305083 |
| Business Phone Number: | 4788258954 |
| Business Fax Number: | |
| Mailing Address: | 555 Bluebird Blvd, P.o. Box 894 FORT VALLEY |
| State: | GA |
| Postal Code: | 310305083 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 07/31/2014 |
| NPI Last Update Date: | 12/10/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | RN198355 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |