Provider Demographics
NPI:1245114628
Name:KOTCH, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KOTCH
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 1:174 ROUTE 715 BROODHEADSVILLE, PA 18322
Mailing Address - Street 2:
Mailing Address - City:BROODHEADSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18322
Mailing Address - Country:US
Mailing Address - Phone:570-977-7707
Mailing Address - Fax:
Practice Address - Street 1:2141 OREGON PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-4604
Practice Address - Country:US
Practice Address - Phone:717-617-2708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN280580164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse