Provider Demographics
NPI:1346795218
Name:SHABAZZ, JUANITA (LPN)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:SHABAZZ
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 1:25501 N LAKELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-2440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 E BAGLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-2058
Practice Address - Country:US
Practice Address - Phone:440-260-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.128751.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse