Provider Demographics
NPI:1225542129
Name:BOHANNON, STACI LYNN (ATC)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:LYNN
Last Name:BOHANNON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 TAMPICO CT
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-2636
Mailing Address - Country:US
Mailing Address - Phone:440-212-1383
Mailing Address - Fax:
Practice Address - Street 1:8585 OH-14
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241
Practice Address - Country:US
Practice Address - Phone:440-212-1383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0048922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer