Healthcare Provider Details

I. General information

NPI: 1114996501
Provider Name (Legal Business Name): SHANNON MARIE TERWILLIGER ATHLETIC TRAINER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7109 BACHMAN RD
SARDINIA OH
45171-8242
US

IV. Provider business mailing address

4701 CREEK RD SUITE 110
BLUE ASH OH
45242-8398
US

V. Phone/Fax

Practice location:
  • Phone: 937-446-3500
  • Fax: 937-446-3559
Mailing address:
  • Phone: 513-733-9333
  • Fax: 513-588-2479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT002318
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: