Provider Demographics
NPI:1558506287
Name:WILLETT, DEANNA K (LPN)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:K
Last Name:WILLETT
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 1:22030 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-2945
Mailing Address - Country:US
Mailing Address - Phone:216-820-1593
Mailing Address - Fax:
Practice Address - Street 1:26250 EUCLID AVE
Practice Address - Street 2:521
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132-3305
Practice Address - Country:US
Practice Address - Phone:216-820-1583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH112903164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
1558506287Medicare Oscar/Certification