Provider Demographics
NPI:1144299843
Name:DULEMBA, SHANE E (NP)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:E
Last Name:DULEMBA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 YANKEE RD
Mailing Address - Street 2:PSYCHIATRY - LIBERTY CAMPUS ML 16066
Mailing Address - City:LIBERTY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-3500
Mailing Address - Country:US
Mailing Address - Phone:513-803-9600
Mailing Address - Fax:
Practice Address - Street 1:7777 YANKEE RD
Practice Address - Street 2:PSYCHIATRY - LIBERTY CAMPUS ML 16066
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-3500
Practice Address - Country:US
Practice Address - Phone:513-803-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.15031-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200532390AMedicaid
IN541910G2Medicare PIN