Basic Information
| Provider Information | |||||||||
| NPI: | 1205307261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUTHER | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ACNPC-AG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 627 EASTLAND AVE SE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444844501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308414000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 627 EASTLAND AVE SE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444844501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308414000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2018 | ||||||||
| LastUpdateDate: | 12/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | APRN.CNP.023809 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.