Provider Demographics
NPI:1598464190
Name:SHANNAK, ROBYN
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:
Last Name:SHANNAK
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 1:131 W GYPSY LANE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-4503
Mailing Address - Country:US
Mailing Address - Phone:419-352-6505
Mailing Address - Fax:
Practice Address - Street 1:131 W GYPSY LANE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-4503
Practice Address - Country:US
Practice Address - Phone:419-352-6505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.11724156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician