Provider Demographics
NPI:1275962987
Name:CRAWFORD, SHANEQUA
Entity Type:Individual
Prefix:
First Name:SHANEQUA
Middle Name:
Last Name:CRAWFORD
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 1:1350 W TH AVENUE
Mailing Address - Street 2:SUITE 14
Mailing Address - City:COLUMBUS
Mailing Address - State:OHIO
Mailing Address - Zip Code:43212
Mailing Address - Country:UM
Mailing Address - Phone:614-290-9247
Mailing Address - Fax:
Practice Address - Street 1:1350 W TH AVENUE
Practice Address - Street 2:SUITE 14
Practice Address - City:COLUMBUS
Practice Address - State:OHIO
Practice Address - Zip Code:43212
Practice Address - Country:UM
Practice Address - Phone:614-290-9247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-03
Last Update Date:2013-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health