MEDICARE: SHANNON N CHAVALIA CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WE0003X	Emergency Registered Nurse	RN.297555	OH
2	363LF0000X	Family Nurse Practitioner	APRN.CNP.0029747	OH

General Provider Information

NPI Number	:	1598434581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON N CHAVALIA CNP

Provider Business Mailing Address
First Line	:	12621 ECKEL JUNCTION RD
Second Line	:
City	:	PERRYSBURG
State	:	OH
Zip	:	43551-1304
Country	:	US
Telephone Number	:	567-368-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 KING RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43617-1406
Country	:	US
Telephone Number	:	567-455-5819
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2021
Last Update Date	:	09/13/2021

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