Provider Demographics
NPI:1215370580
Name:DEW, SHANNA LEE (NP)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:LEE
Last Name:DEW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:LEE
Other - Last Name:BURNSIDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1370 N STATE ROUTE 377 NW
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:OH
Mailing Address - Zip Code:43758-9786
Mailing Address - Country:US
Mailing Address - Phone:740-607-3625
Mailing Address - Fax:
Practice Address - Street 1:1370 N STATE ROUTE 377 NW
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:OH
Practice Address - Zip Code:43758-9786
Practice Address - Country:US
Practice Address - Phone:740-607-3625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN375151163W00000X
OHAPRN.CNP.023718363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse