Provider Demographics
NPI:1124323159
Name:FANNIN, GLENEISHA LATRIECE (LPN)
Entity type:Individual
Prefix:MS
First Name:GLENEISHA
Middle Name:LATRIECE
Last Name:FANNIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 BEAR CREEK DR
Mailing Address - Street 2:127
Mailing Address - City:BEDFORD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-2971
Mailing Address - Country:US
Mailing Address - Phone:216-313-2884
Mailing Address - Fax:
Practice Address - Street 1:6000 BEAR CREEK DR
Practice Address - Street 2:127
Practice Address - City:BEDFORD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44146-2971
Practice Address - Country:US
Practice Address - Phone:216-313-2884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-23
Last Update Date:2011-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH143053164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse