Provider Demographics
NPI:1841752425
Name:WILSON, SHANNON MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:WILSON
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 1:38 S THOMAS RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-2100
Mailing Address - Country:US
Mailing Address - Phone:330-805-0577
Mailing Address - Fax:
Practice Address - Street 1:38 S THOMAS RD UNIT B
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-2100
Practice Address - Country:US
Practice Address - Phone:330-805-0577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.162856.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse