Provider Demographics
NPI:1518377936
Name:O'NEAL, SHASTA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SHASTA
Middle Name:
Last Name:O'NEAL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:SHASTA
Other - Middle Name:
Other - Last Name:EDMONDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:72 N. THOMAS RD
Mailing Address - Street 2:APT 10 B
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:72 N. THOMAS RD
Practice Address - Street 2:APT 10 B
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278
Practice Address - Country:US
Practice Address - Phone:330-999-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141140164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse