=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205074515
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHEVONNE MONIQUE CHAMBLISS L.P.N.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2009
-----------------------------------------------------
Last Update Date | 01/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9411 ANDERSON
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-298-3916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9411 ANDERSON AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44105-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-298-3916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | PN126603
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------