Provider Demographics
NPI:1578849964
Name:ADDIE, TANESHA NICHOLE (LPN)
Entity Type:Individual
Prefix:
First Name:TANESHA
Middle Name:NICHOLE
Last Name:ADDIE
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:PO BOX 1493
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44309-1493
Mailing Address - Country:US
Mailing Address - Phone:330-415-4169
Mailing Address - Fax:
Practice Address - Street 1:1765 E WATERFORD CT
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-8366
Practice Address - Country:US
Practice Address - Phone:330-510-6546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-29
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131334IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0056892Medicaid