Provider Demographics
NPI:1215420013
Name:CHATHAM, SHANNON LYNN (DO)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:CHATHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 LOCUST AVE EXT
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:PA
Mailing Address - Zip Code:15349-1355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5151 MORNING SUN RD STE D
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-9546
Practice Address - Country:US
Practice Address - Phone:513-523-4195
Practice Address - Fax:513-523-4353
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
OH34.015237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2565399Medicaid