Provider Demographics
NPI:1972973170
Name:PRIKKEL, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PRIKKEL
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 1:4001 OLD SALEM RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-2681
Mailing Address - Country:US
Mailing Address - Phone:937-832-5000
Mailing Address - Fax:937-832-5001
Practice Address - Street 1:4001 OLD SALEM RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2681
Practice Address - Country:US
Practice Address - Phone:937-832-5000
Practice Address - Fax:937-832-5001
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH392899163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPRIKKELSMedicaid