=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619515731
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON M HOUSLEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2019
-----------------------------------------------------
Last Update Date | 12/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11006 READING RD STE 102
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45241-1981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-454-6911
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11729 WOODWIND DR
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45140-1927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-490-3639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZA2600X
-----------------------------------------------------
Taxonomy Name | Medical Art Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------