Basic Information
| Provider Information | |||||||||
| NPI: | 1740266501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUTHERLAND | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | RENAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUCENTE | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | RENAE | ||||||||
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| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5901 MONCLOVA RD | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198723201 | ||||||||
| FaxNumber: | 4198723208 | ||||||||
| Practice Location | |||||||||
| Address1: | 1103 VILLAGE SQUARE DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435511783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198723219 | ||||||||
| FaxNumber: | 4198723208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 01/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | BL9255058 | OH | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 34.008522 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2604793 | 05 | OH | MEDICAID |