Provider Demographics
NPI:1801476940
Name:GANNON, TEENA MARIE
Entity type:Individual
Prefix:
First Name:TEENA
Middle Name:MARIE
Last Name:GANNON
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 1:2657 COUNTY ROAD 18
Mailing Address - Street 2:
Mailing Address - City:SOUTH POINT
Mailing Address - State:OH
Mailing Address - Zip Code:45680-7382
Mailing Address - Country:US
Mailing Address - Phone:740-302-7354
Mailing Address - Fax:
Practice Address - Street 1:1035 COUNTY ROAD 1 APT.215
Practice Address - Street 2:
Practice Address - City:SOUTH POINT
Practice Address - State:OH
Practice Address - Zip Code:45680-7382
Practice Address - Country:US
Practice Address - Phone:740-302-7354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRP5826683747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1022401OtherCHOICES
OH1022Q401Medicaid