MEDICARE: KISHA JEFFERSON STNA

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	251E00000X	Home Health Agency	322541220114	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104352657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KISHA JEFFERSON STNA

Provider Business Mailing Address
First Line	:	3788 W 130TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-3319
Country	:	US
Telephone Number	:	216-801-9227
Fax Number	:

Provider Business Practice Location Address
First Line	:	3788 W 130TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-3319
Country	:	US
Telephone Number	:	216-801-9227
Fax Number	:

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

Provider Enumeration Date	:	05/03/2017
Last Update Date	:	05/03/2017

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Directions to “ KISHA JEFFERSON STNA” Practice Location

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