Provider Demographics
NPI:1780350728
Name:SHANNON, KRISTINE M (CNP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:SHANNON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1097 DEERHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-2270
Mailing Address - Country:US
Mailing Address - Phone:513-560-5162
Mailing Address - Fax:
Practice Address - Street 1:3590 LUCILLE DR STE 2200
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45213-2666
Practice Address - Country:US
Practice Address - Phone:513-458-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLE00037947363L00000X
OHAPRN.CNP.0029784363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner