Provider Demographics
NPI:1164647301
Name:DEBARDELABEN, TIESHA SHAREASE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TIESHA
Middle Name:SHAREASE
Last Name:DEBARDELABEN
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 1:1453 WESTOVER RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-1341
Mailing Address - Country:US
Mailing Address - Phone:216-320-9662
Mailing Address - Fax:
Practice Address - Street 1:1453 WESTOVER RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1341
Practice Address - Country:US
Practice Address - Phone:216-320-9662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.114862164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2550190Medicaid