Healthcare Provider Details

I. General information

NPI: 1407251523
Provider Name (Legal Business Name): HEATHER M SHOUP CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2014
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 MIAMI VALLEY DR STE 500
DAYTON OH
45459-4780
US

IV. Provider business mailing address

6680 POE AVE STE 200
DAYTON OH
45414-2855
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-1622
  • Fax: 937-245-6308
Mailing address:
  • Phone: 937-280-8400
  • Fax: 937-280-8373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN317714
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCOA16815NP
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.CNP.16815
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: