Provider Demographics
NPI:1205633260
Name:BACCHUS, MAELYN BIANCA
Entity type:Individual
Prefix:
First Name:MAELYN
Middle Name:BIANCA
Last Name:BACCHUS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26241 LAKE SHORE BLVD APT 1264
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-1145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20611 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-1521
Practice Address - Country:US
Practice Address - Phone:216-859-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.517631164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse