MEDICARE: MS. TANISHA BRIANNA BACON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide
2	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1750006680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TANISHA BRIANNA BACON

Provider Business Mailing Address
First Line	:	10824 OLIVET AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-3528
Country	:	US
Telephone Number	:	216-688-5977
Fax Number	:

Provider Business Practice Location Address
First Line	:	10824 OLIVET AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-3528
Country	:	US
Telephone Number	:	216-688-5977
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2022
Last Update Date	:	10/11/2022

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