Healthcare Provider Details

I. General information

NPI: 1366657983
Provider Name (Legal Business Name): SHANNON TEANNA WADE IP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 GRACE AVE
AKRON OH
44320-2151
US

IV. Provider business mailing address

336 GRACE AVE
AKRON OH
44320-2151
US

V. Phone/Fax

Practice location:
  • Phone: 330-620-8077
  • Fax:
Mailing address:
  • Phone: 330-620-8077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SH0200X
TaxonomyHome Health Clinical Nurse Specialist
License Number2420946
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: