Provider Demographics
NPI:1740622257
Name:JANEZIC, NATHANIEL ALTON
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:ALTON
Last Name:JANEZIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E 47TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-6121
Mailing Address - Country:US
Mailing Address - Phone:716-848-0989
Mailing Address - Fax:
Practice Address - Street 1:1801 E 47TH ST
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6121
Practice Address - Country:US
Practice Address - Phone:716-848-0989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401266610711376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide