Provider Demographics
NPI:1831240381
Name:PREMIER PRACTITIONERS, LLC
Entity type:Organization
Organization Name:PREMIER PRACTITIONERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHANK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:419-266-5762
Mailing Address - Street 1:22650 AULT RD
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-8953
Mailing Address - Country:US
Mailing Address - Phone:419-266-5762
Mailing Address - Fax:419-833-1123
Practice Address - Street 1:22650 AULT RD
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-8953
Practice Address - Country:US
Practice Address - Phone:419-266-5762
Practice Address - Fax:419-833-1123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP03335363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2547373Medicaid
OH2547373Medicaid