Provider Demographics
NPI:1669228482
Name:EASON, SHAVONTAE R
Entity type:Individual
Prefix:
First Name:SHAVONTAE
Middle Name:R
Last Name:EASON
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 1:443 RICHMOND PARK W APT 617D
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-1895
Mailing Address - Country:US
Mailing Address - Phone:216-256-9869
Mailing Address - Fax:
Practice Address - Street 1:443 RICHMOND PARK W APT 617D
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-1895
Practice Address - Country:US
Practice Address - Phone:216-256-9869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHFPS.000138175T00000X
OHAPS.004857175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist