Provider Demographics
NPI:1609471176
Name:ANDERSON, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ANDERSON
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 1:52205 BARNES ST
Mailing Address - Street 2:
Mailing Address - City:JERUSALEM
Mailing Address - State:OH
Mailing Address - Zip Code:43747-9662
Mailing Address - Country:US
Mailing Address - Phone:740-827-4247
Mailing Address - Fax:
Practice Address - Street 1:52205 BARNES ST
Practice Address - Street 2:
Practice Address - City:JERUSALEM
Practice Address - State:OH
Practice Address - Zip Code:43747-9662
Practice Address - Country:US
Practice Address - Phone:740-827-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
No251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle