Provider Demographics
NPI:1053914374
Name:LEE, SHANNAN L (INDEPENDENT PROVIDER)
Entity type:Individual
Prefix:
First Name:SHANNAN
Middle Name:L
Last Name:LEE
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 GARVER RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-8923
Mailing Address - Country:US
Mailing Address - Phone:513-435-2716
Mailing Address - Fax:
Practice Address - Street 1:860 GARVER RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-8923
Practice Address - Country:US
Practice Address - Phone:513-435-2716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X, 385H00000X, 385HR2060X
OH0906797376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0387419Medicaid