Provider Demographics
NPI:1114587334
Name:FRAZIER, THERESA MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MICHELLE
Last Name:FRAZIER
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 1:1321 SPRING AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44714-2473
Mailing Address - Country:US
Mailing Address - Phone:330-412-5607
Mailing Address - Fax:
Practice Address - Street 1:1321 SPRING AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44714-2473
Practice Address - Country:US
Practice Address - Phone:330-412-5607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.132750.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse