Provider Demographics
NPI:1639610561
Name:MOSS, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MOSS
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 1:746 MARION AVE SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-4371
Mailing Address - Country:US
Mailing Address - Phone:330-313-0919
Mailing Address - Fax:
Practice Address - Street 1:746 MARION AVE SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-4371
Practice Address - Country:US
Practice Address - Phone:330-313-0919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-11
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2551877Medicaid