Provider Demographics
NPI:1770707341
Name:BOESHART, SHANNON MARIE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:BOESHART
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 1:13905 ARMENTROUT RD.
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43019
Mailing Address - Country:US
Mailing Address - Phone:740-694-1381
Mailing Address - Fax:
Practice Address - Street 1:13905 ARMENTROUT RD
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:OH
Practice Address - Zip Code:43019-9717
Practice Address - Country:US
Practice Address - Phone:740-694-1381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN299709163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse