Provider Demographics
NPI:1366657983
Name:WADE, SHANNON TEANNA (IP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:TEANNA
Last Name:WADE
Suffix:
Gender:F
Credentials:IP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-2151
Mailing Address - Country:US
Mailing Address - Phone:330-620-8077
Mailing Address - Fax:
Practice Address - Street 1:336 GRACE AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2151
Practice Address - Country:US
Practice Address - Phone:330-620-8077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2420946364SH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome Health