Healthcare Provider Details

I. General information

NPI: 1750795076
Provider Name (Legal Business Name): MISS SHANNON HULL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3823 FOREST RIDGE CT
MINERAL RIDGE OH
44440-9775
US

IV. Provider business mailing address

3823 FOREST RIDGE CT
MINERAL RIDGE OH
44440-9775
US

V. Phone/Fax

Practice location:
  • Phone: 330-307-0359
  • Fax:
Mailing address:
  • Phone: 330-307-0359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number400569511206
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: