Provider Demographics
NPI:1386359289
Name:MOSELY, SHANETHIA
Entity type:Individual
Prefix:
First Name:SHANETHIA
Middle Name:
Last Name:MOSELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 COMMUNITY LN
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-3000
Mailing Address - Country:US
Mailing Address - Phone:216-403-1861
Mailing Address - Fax:
Practice Address - Street 1:13201 GRANGER RD STE 8
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44125-1979
Practice Address - Country:US
Practice Address - Phone:216-403-1861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0159424Medicaid