Healthcare Provider Details

I. General information

NPI: 1417643545
Provider Name (Legal Business Name): SHANNON YEAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 W MAIN ST
CLARKSBURG WV
26301-2630
US

IV. Provider business mailing address

PO BOX 168
GYPSY WV
26361-0168
US

V. Phone/Fax

Practice location:
  • Phone: 304-842-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: