Provider Demographics
NPI:1194239475
Name:SHOCKLING, KATIE LYNN
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:SHOCKLING
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 1:1723 CARRIAGE LN APT 304
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-3577
Mailing Address - Country:US
Mailing Address - Phone:330-495-4039
Mailing Address - Fax:
Practice Address - Street 1:4641 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2384
Practice Address - Country:US
Practice Address - Phone:330-433-6075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program