Provider Demographics
NPI:1982168860
Name:DONOVAN, SHIANNE
Entity type:Individual
Prefix:
First Name:SHIANNE
Middle Name:
Last Name:DONOVAN
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 1:450 ERIE ST
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-2200
Mailing Address - Country:US
Mailing Address - Phone:814-734-1618
Mailing Address - Fax:
Practice Address - Street 1:450 ERIE ST
Practice Address - Street 2:
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412
Practice Address - Country:US
Practice Address - Phone:814-734-1618
Practice Address - Fax:814-734-3102
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
PAOA007016363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer