Provider Demographics
NPI:1639877400
Name:SWAN, SHAREESE LYNNETTE
Entity Type:Individual
Prefix:
First Name:SHAREESE
Middle Name:LYNNETTE
Last Name:SWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6094 RIVER STYX RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-9782
Mailing Address - Country:US
Mailing Address - Phone:330-760-4515
Mailing Address - Fax:
Practice Address - Street 1:4141 PEARL RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-7649
Practice Address - Country:US
Practice Address - Phone:330-723-0234
Practice Address - Fax:330-723-1608
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
OHOP.005815-SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No374U00000XNursing Service Related ProvidersHome Health Aide