Provider Demographics
NPI:1033594882
Name:SHAGOVAC, TESSA F (LPN)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:F
Last Name:SHAGOVAC
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6753 STATE RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-4517
Mailing Address - Country:US
Mailing Address - Phone:440-843-5565
Mailing Address - Fax:
Practice Address - Street 1:6753 STATE RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-4517
Practice Address - Country:US
Practice Address - Phone:440-843-5565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH152069164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse