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2020032 Special Needs Shelter Medical Services <br />Company Name <br />Registrations <br />Years of Experience in <br />this Classification <br />Tax ID Number <br />I.{-1 - L� U 'S/(Zy ►�j w_g <br />Attached <br />Contact Name <br />Phone <br />Simi-qC-L--y <br />Title <br />CL Ci Email ►!��() �,C(�i��kVCSc)J�l�. <br />Address <br />Z DAI-U ST 5 j . re, 341- k'Yj <br />CN A & <br />LW,2 <br />LAM Qeu �. LJ i <br />L I C.*�- <br />C�- AIZ6 <br />CNA/Home Health Aide <br />List qualifications of individual providers currently on staff who may be utilized under this <br />contract (names not required). Minimum providers are listed below, but please use additional <br />lines, and sheets, if necessary, to provide qualifications for additional providers, by <br />classification: <br />Provider Classification <br />Registrations <br />Years of Experience in <br />this Classification <br />Nurse <br />ti_' # <br />f�� 9381 2&S <br />ErreS <br />Nurse <br />LIC H <br />Pi\1 9 2- 1 LI 1(, -70 <br />,Y 'gCAc2S <br />CNA/Home Health Aide <br />Ll L# <br />CN A & <br />LW,2 <br />CNA/Home Health Aide <br />L I C.*�- <br />C�- AIZ6 <br />CNA/Home Health Aide <br />L I c O- <br />GtvA '2— 0 3 <br />- OY&S <br />CNA/Home Health Aide <br />Lk E- *` <br />C fQ 3t,-) G31 <br />CNA/Home Health Aide <br />i t# <br />C jq 3 i 5 -7 q 3 <br />CNA/Home Health Aide <br />I- I L kA <br />CN Y y to 11 lv <br />! S f E S <br />Respiratory Assistant <br />L (-# <br />letjR 4 3 2-9 -7 a <br />Ff�rLs <br />Page 15 of 31 <br />C._ <br />S. Czwn <br />