Provider Demographics
NPI:1386902161
Name:JANUS-SHATTUCK, RAELENE A (PN140739-M-IV)
Entity type:Individual
Prefix:
First Name:RAELENE
Middle Name:A
Last Name:JANUS-SHATTUCK
Suffix:
Gender:F
Credentials:PN140739-M-IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 GANYARD AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-2717
Mailing Address - Country:US
Mailing Address - Phone:216-926-7730
Mailing Address - Fax:
Practice Address - Street 1:4001 GANYARD AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-2717
Practice Address - Country:US
Practice Address - Phone:330-220-8431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.140739-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse