Provider Demographics
NPI:1568597870
Name:GORMAN, SHANNON MARIE
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:MARIE
Last Name:GORMAN
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 1:3801 BRENDAN LANE
Mailing Address - Street 2:C4
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070
Mailing Address - Country:US
Mailing Address - Phone:440-734-4163
Mailing Address - Fax:
Practice Address - Street 1:3801 BRENDAN LANE
Practice Address - Street 2:C4
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070
Practice Address - Country:US
Practice Address - Phone:440-734-4163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2074777Medicaid