Provider Demographics
NPI:1780075838
Name:SHREVES, KRISTINE CAROLINE (LPN-M-IV)
Entity type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:CAROLINE
Last Name:SHREVES
Suffix:
Gender:F
Credentials:LPN-M-IV
Other - Prefix:MISS
Other - First Name:KRISTINE
Other - Middle Name:CAROLINE
Other - Last Name:GRINSTEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN-M-IV
Mailing Address - Street 1:36603 S LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:EASTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44095-1345
Mailing Address - Country:US
Mailing Address - Phone:440-342-0256
Mailing Address - Fax:
Practice Address - Street 1:36603 S LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:EASTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44095-1345
Practice Address - Country:US
Practice Address - Phone:440-342-0256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH112156164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse