Provider Demographics
NPI:1114234507
Name:SHANNON, REBECCA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 ADELITE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3208
Mailing Address - Country:US
Mailing Address - Phone:937-701-1927
Mailing Address - Fax:
Practice Address - Street 1:444 ADELITE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3208
Practice Address - Country:US
Practice Address - Phone:937-701-1927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140332164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse