Provider Demographics
NPI:1063887180
Name:SHANNON DAVIS PRIVATE NURSING CARE
Entity type:Organization
Organization Name:SHANNON DAVIS PRIVATE NURSING CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-608-3620
Mailing Address - Street 1:5814 GREEN CREST DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-2222
Mailing Address - Country:US
Mailing Address - Phone:513-608-3620
Mailing Address - Fax:
Practice Address - Street 1:5814 GREEN CREST DR
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-2222
Practice Address - Country:US
Practice Address - Phone:513-608-3620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH119585251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH166946Medicaid