Provider Demographics
NPI:1386461556
Name:BACCHUS, MONICA RENA'
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:RENA'
Last Name:BACCHUS
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 1:15216 ROWENA AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-4822
Mailing Address - Country:US
Mailing Address - Phone:216-816-5727
Mailing Address - Fax:
Practice Address - Street 1:15216 ROWENA AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-4822
Practice Address - Country:US
Practice Address - Phone:216-816-5727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH9999999999374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide