Provider Demographics
NPI:1912545989
Name:SHANKS, PAMELA SUE (LPN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:SHANKS
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 1:116 DEWEY DR
Mailing Address - Street 2:
Mailing Address - City:SARDINIA
Mailing Address - State:OH
Mailing Address - Zip Code:45171-9598
Mailing Address - Country:US
Mailing Address - Phone:937-336-7368
Mailing Address - Fax:
Practice Address - Street 1:313 CHILLICOTHE AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-7378
Practice Address - Country:US
Practice Address - Phone:937-393-4562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH126702164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse