Provider Demographics
NPI:1174767677
Name:TENNANT, SHANNON L (PT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:TENNANT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-992-0060
Mailing Address - Fax:740-446-5154
Practice Address - Street 1:88 EAST MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:POMEROY
Practice Address - State:OH
Practice Address - Zip Code:45769
Practice Address - Country:US
Practice Address - Phone:740-992-0060
Practice Address - Fax:740-446-5154
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH012394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1174767677OtherMED MUTAL OF OHIO
OH000000270651OtherOH MEDICAID UNISON
WV3810014932Medicaid
OH2970129OtherOH MEDICAID MOLINA
OH2970129Medicaid
OHP00794068OtherRAILROAD MEDICARE
OH000000270651OtherOH MEDICAID UNISON