Provider Demographics
NPI:1396199733
Name:SMITH, SHANE TODD (RN)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:TODD
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 ROTHROCK DR
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-8692
Mailing Address - Country:US
Mailing Address - Phone:614-266-2744
Mailing Address - Fax:
Practice Address - Street 1:725 ROTHROCK DR
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:OH
Practice Address - Zip Code:43119-8692
Practice Address - Country:US
Practice Address - Phone:614-266-2744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-342389163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency