Provider Demographics
NPI:1407251523
Name:SHOUP, HEATHER M (CNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:SHOUP
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6680 POE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2855
Mailing Address - Country:US
Mailing Address - Phone:937-280-8400
Mailing Address - Fax:937-280-8373
Practice Address - Street 1:2350 MIAMI VALLEY DR STE 500
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4780
Practice Address - Country:US
Practice Address - Phone:937-293-1622
Practice Address - Fax:937-245-6308
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-31
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN317714163W00000X
OHCOA16815NP363L00000X
OHAPRN.CNP.16815363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0113882Medicaid
OH0113882Medicaid