Provider Demographics
NPI:1992994800
Name:GLICK, SHONDA LEIGH (LPN)
Entity type:Individual
Prefix:
First Name:SHONDA
Middle Name:LEIGH
Last Name:GLICK
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 1:7757 TOWNSHIP ROAD 169
Mailing Address - Street 2:
Mailing Address - City:GREEN SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:44836-9749
Mailing Address - Country:US
Mailing Address - Phone:419-603-6557
Mailing Address - Fax:
Practice Address - Street 1:7757 TOWNSHIP ROAD 169
Practice Address - Street 2:
Practice Address - City:GREEN SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:44836-9749
Practice Address - Country:US
Practice Address - Phone:419-603-6557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN116096164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse