Healthcare Provider Details

I. General information

NPI: 1609518604
Provider Name (Legal Business Name): DEANNA K ABDELLAH PRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEANNA WEAVER

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 NAVE RD SE
MASSILLON OH
44646-9604
US

IV. Provider business mailing address

625 CLEVELAND AVE NW
CANTON OH
44702-1805
US

V. Phone/Fax

Practice location:
  • Phone: 330-830-8740
  • Fax: 330-830-0912
Mailing address:
  • Phone: 330-455-0374
  • Fax: 330-453-6719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.003304
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: