Provider Demographics
NPI:1144459041
Name:SHUPERT, DANETTA J
Entity type:Individual
Prefix:
First Name:DANETTA
Middle Name:J
Last Name:SHUPERT
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 1:71 OVER DR
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:OH
Mailing Address - Zip Code:45693-9203
Mailing Address - Country:US
Mailing Address - Phone:937-544-2606
Mailing Address - Fax:
Practice Address - Street 1:71 OVER DR
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:OH
Practice Address - Zip Code:45693-9203
Practice Address - Country:US
Practice Address - Phone:937-544-2606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2929424374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2929424Medicaid