Provider Demographics
NPI:1184486086
Name:SHANNON, KELLY GRACE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:GRACE
Last Name:SHANNON
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 1:14664 DECOURCEY ST
Mailing Address - Street 2:
Mailing Address - City:RITTMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44270-1010
Mailing Address - Country:US
Mailing Address - Phone:330-398-8835
Mailing Address - Fax:
Practice Address - Street 1:14664 DECOURCEY ST
Practice Address - Street 2:
Practice Address - City:RITTMAN
Practice Address - State:OH
Practice Address - Zip Code:44270-1010
Practice Address - Country:US
Practice Address - Phone:330-398-8835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker