Healthcare Provider Details

I. General information

NPI: 1639049356
Provider Name (Legal Business Name): SHANNON BUTERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2025
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6085 PILOT KNOB AVE NE
LOUISVILLE OH
44641-9254
US

IV. Provider business mailing address

6085 PILOT KNOB AVE NE
LOUISVILLE OH
44641-9254
US

V. Phone/Fax

Practice location:
  • Phone: 330-418-0684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberSU184222
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: