Provider Demographics
NPI:1154454874
Name:GRAVITT, SHANNON M (RN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:GRAVITT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-2836
Mailing Address - Country:US
Mailing Address - Phone:513-307-8993
Mailing Address - Fax:
Practice Address - Street 1:122 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215-2836
Practice Address - Country:US
Practice Address - Phone:513-307-8993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-321190163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse