Provider Demographics
NPI:1407497464
Name:BOUGH, SHANNON R (CSFA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:BOUGH
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 YANKEE RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TWP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-3500
Mailing Address - Country:US
Mailing Address - Phone:513-803-9600
Mailing Address - Fax:
Practice Address - Street 1:7777 YANKEE RD
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-3500
Practice Address - Country:US
Practice Address - Phone:513-803-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant