Provider Demographics
NPI:1467584995
Name:EGLEBERRY, MICHELLE RENEE' (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE'
Last Name:EGLEBERRY
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 1:7441 SABRE AVE
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-1845
Mailing Address - Country:US
Mailing Address - Phone:614-759-0870
Mailing Address - Fax:
Practice Address - Street 1:7441 SABRE AVE
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-1845
Practice Address - Country:US
Practice Address - Phone:614-759-0870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
OHPN126606164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2104396Medicaid
OH105643189199Medicaid