1740205129 NPI number — KARRIE A SHANNON PT

Table of content: KARRIE A SHANNON PT (NPI 1740205129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740205129 NPI number — KARRIE A SHANNON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANNON
Provider First Name:
KARRIE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740205129
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1257 FOXFIRE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAINESVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44077-5257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-974-2250
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35000 KAISER CT
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
WILLOUGHBY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44094-3382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-951-6677
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 009156 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2622755 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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