Provider Demographics
NPI:1629286869
Name:ROBERTS, SHANNON NICOLE (STNA, PCT, MT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:STNA, PCT, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 FLINTHILL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43223-3542
Mailing Address - Country:US
Mailing Address - Phone:614-305-3569
Mailing Address - Fax:
Practice Address - Street 1:1813 FLINTHILL DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-3542
Practice Address - Country:US
Practice Address - Phone:614-305-3569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH320578730298376K00000X
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered376K00000XNursing Service Related ProvidersNurse's Aide
Not Answered3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant