Provider Demographics
NPI:1396498788
Name:HUBBARD, DEMETRIA RENAE
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:RENAE
Last Name:HUBBARD
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 1:4786 DRESSLER RD NW STE 173
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2555
Mailing Address - Country:US
Mailing Address - Phone:440-661-7920
Mailing Address - Fax:
Practice Address - Street 1:5877 PORTAGE ST NW # NA
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-6770
Practice Address - Country:US
Practice Address - Phone:330-936-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747A0650X, 3747P1801X
OH179251164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant