Provider Demographics
NPI:1194415513
Name:TERRY, SHAWN DWAYNE (COMMERCIAL DRIVER)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:DWAYNE
Last Name:TERRY
Suffix:
Gender:M
Credentials:COMMERCIAL DRIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 BROERMAN AVE APT B4
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45217-1136
Mailing Address - Country:US
Mailing Address - Phone:513-687-3940
Mailing Address - Fax:
Practice Address - Street 1:5120 BROERMAN AVE APT B4
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45217-1136
Practice Address - Country:US
Practice Address - Phone:513-687-3940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN915945171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications