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General NPI Number Information
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NPI Number | 1801476940
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Entity Type | Individual
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Provider Name | TEENA MARIE GANNON
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Gender | Female
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Dates
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Enumeration Date | 04/13/2021
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Last Update Date | 04/13/2021
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Provider Practice Location Address
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Address Line | 1035 COUNTY ROAD 1 APT.215
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City | SOUTH POINT
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State | OH
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Zip | 45680-7382
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Country | US
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Telephone | 740-302-7354
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Fax |
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Provider Business Mailing Address
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Address Line | 2657 COUNTY ROAD 18
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City | SOUTH POINT
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State | OH
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Zip | 45680-7382
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Country | US
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Telephone | 740-302-7354
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3747A0650X
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Taxonomy Name | Attendant Care Provider
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License Number | RP582668
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License Number State | OH
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