Provider Demographics
NPI:1215534847
Name:WEIKERT, SHANNON DIMETRA
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DIMETRA
Last Name:WEIKERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4577 CRYSTAL BALL DR
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-2803
Mailing Address - Country:US
Mailing Address - Phone:937-360-9643
Mailing Address - Fax:
Practice Address - Street 1:4577 CRYSTAL BALL DR
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-2803
Practice Address - Country:US
Practice Address - Phone:937-360-9643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33019127225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist