Healthcare Provider Details

I. General information

NPI: 1356277420
Provider Name (Legal Business Name): SAMANTHA SHANNON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 N SWIFT RD
ADDISON IL
60101-6105
US

IV. Provider business mailing address

3882 SNOWSHOE AVE
GROVE CITY OH
43123-1195
US

V. Phone/Fax

Practice location:
  • Phone: 614-252-8890
  • Fax:
Mailing address:
  • Phone: 740-505-1696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0042450
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: