Provider Demographics
NPI:1750795076
Name:HULL, SHANNON
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:
Last Name:HULL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 FOREST RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MINERAL RIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:44440-9775
Mailing Address - Country:US
Mailing Address - Phone:330-307-0359
Mailing Address - Fax:
Practice Address - Street 1:3823 FOREST RIDGE CT
Practice Address - Street 2:
Practice Address - City:MINERAL RIDGE
Practice Address - State:OH
Practice Address - Zip Code:44440-9775
Practice Address - Country:US
Practice Address - Phone:330-307-0359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400569511206376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0087517Medicaid