Healthcare Provider Details

I. General information

NPI: 1487577151
Provider Name (Legal Business Name): SHANNON LOUISE VERGARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17273 STATE ROUTE 104
CHILLICOTHEE OH
45601-9718
US

IV. Provider business mailing address

5261 GOLDEN FERN LN
COLUMBUS OH
43228-2734
US

V. Phone/Fax

Practice location:
  • Phone: 740-773-1141
  • Fax:
Mailing address:
  • Phone: 740-773-1141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4027497
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: