Provider Demographics
NPI:1568898583
Name:SHANE, PEGGY LYNNE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:LYNNE
Last Name:SHANE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10285 DOWLING RD
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-9627
Mailing Address - Country:US
Mailing Address - Phone:419-308-9736
Mailing Address - Fax:
Practice Address - Street 1:10285 DOWLING RD
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-9627
Practice Address - Country:US
Practice Address - Phone:419-308-9736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN146621164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse