Provider Demographics
NPI:1588215172
Name:DAVIS, SHANNON C (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:C
Last Name:DAVIS
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 1:1233 UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-9378
Mailing Address - Country:US
Mailing Address - Phone:480-203-8441
Mailing Address - Fax:
Practice Address - Street 1:2652 KULL RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-7707
Practice Address - Country:US
Practice Address - Phone:740-277-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN142596-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse