Provider Demographics
NPI:1891517538
Name:MCKINNIE, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MCKINNIE
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 1:12006 MASON WAY CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45249-2800
Mailing Address - Country:US
Mailing Address - Phone:513-628-3196
Mailing Address - Fax:
Practice Address - Street 1:12006 MASON WAY CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-2800
Practice Address - Country:US
Practice Address - Phone:513-628-3196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant