Provider Demographics
NPI:1184001059
Name:SHAFFER, TINA RENEE
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:RENEE
Last Name:SHAFFER
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 1:5875 WILLOW CHASE CIR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-8374
Mailing Address - Country:US
Mailing Address - Phone:937-342-0605
Mailing Address - Fax:
Practice Address - Street 1:5875 WILLOW CHASE CIR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-8374
Practice Address - Country:US
Practice Address - Phone:937-342-0605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH318802163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse