Provider Demographics
NPI:1184989741
Name:PETTAWAY, SHANNON SHANTILL (LPN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:SHANTILL
Last Name:PETTAWAY
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 1:1156 CORBIN RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-2321
Mailing Address - Country:US
Mailing Address - Phone:419-469-2719
Mailing Address - Fax:
Practice Address - Street 1:1156 CORBIN RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-2321
Practice Address - Country:US
Practice Address - Phone:419-469-2719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN144565MIV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse