Provider Demographics
NPI:1083830038
Name:KNYSZEK, SHELLE ANN (LPN)
Entity Type:Individual
Prefix:
First Name:SHELLE
Middle Name:ANN
Last Name:KNYSZEK
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 1:1322 BENTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-9785
Mailing Address - Country:US
Mailing Address - Phone:419-564-5710
Mailing Address - Fax:
Practice Address - Street 1:1322 BENTWOOD CT
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-9785
Practice Address - Country:US
Practice Address - Phone:419-564-5710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN103777164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1062057375-99Medicaid