Provider Demographics
NPI:1104547934
Name:BRODESS, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:BRODESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST MILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45383-1342
Mailing Address - Country:US
Mailing Address - Phone:937-418-3301
Mailing Address - Fax:
Practice Address - Street 1:4100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428-9000
Practice Address - Country:US
Practice Address - Phone:937-268-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH381510163WG0000X, 163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice