Provider Demographics
NPI:1689371114
Name:SHANNON, BROOKE (LDO)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 DUNDEE CIR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2118
Mailing Address - Country:US
Mailing Address - Phone:937-344-5959
Mailing Address - Fax:
Practice Address - Street 1:8800 KINGSRIDGE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-1616
Practice Address - Country:US
Practice Address - Phone:937-436-3472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician