Provider Demographics
NPI:1972316644
Name:BLASZKOWSKI, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BLASZKOWSKI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 E FOSTERS MAINEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MAINEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45039-8298
Mailing Address - Country:US
Mailing Address - Phone:586-615-8438
Mailing Address - Fax:
Practice Address - Street 1:2211 FULTON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206-2504
Practice Address - Country:US
Practice Address - Phone:513-961-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-28
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS2504128-TRNE390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program