Basic Information
| Provider Information | |||||||||
| NPI: | 1932308707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COUVREUR | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | VITALE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AMBULANCE DR 202 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388710 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 HENRY BURSON AVE 215 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301174466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702142121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 066586 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 003112931A | 05 | GA | MEDICAID |