=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972262632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANA KIESWETTER RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2021
-----------------------------------------------------
Last Update Date | 07/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1508 W RIVER RD N
-----------------------------------------------------
City | ELYRIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44035-2714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-647-8100
-----------------------------------------------------
Fax | 440-426-8375
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4200 LEAVITT RD
-----------------------------------------------------
City | LORAIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44053-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | LPN.179620.MEDS-IV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Registered Nurse
-----------------------------------------------------
License Number | RN.542140
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------