Provider Demographics
NPI:1982588471
Name:HAIRSTON, IESHA SHANAE (LPN)
Entity type:Individual
Prefix:
First Name:IESHA
Middle Name:SHANAE
Last Name:HAIRSTON
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 1:762 PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-4018
Mailing Address - Country:US
Mailing Address - Phone:312-937-8466
Mailing Address - Fax:312-937-8466
Practice Address - Street 1:762 PULASKI RD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-4018
Practice Address - Country:US
Practice Address - Phone:312-937-8466
Practice Address - Fax:312-937-8466
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.133335164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse