Provider Demographics
NPI:1659861540
Name:SMITH, SHANNON NICHOLE (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICHOLE
Last Name:SMITH
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 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-453-6716
Practice Address - Street 1:200 E STATE ST FL 3
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4936
Practice Address - Country:US
Practice Address - Phone:330-821-8503
Practice Address - Fax:330-627-0088
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN149936MEDSIV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse