Healthcare Provider Details

I. General information

NPI: 1124433495
Provider Name (Legal Business Name): SHANNON M HAIKALIS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

2830 VICTORY PKWY
CINCINNATI OH
45206-1785
US

V. Phone/Fax

Practice location:
  • Phone: 513-584-7425
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number3009359
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA16053NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: