MEDICARE: MISS CICEL RENEE YOUNG LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	313244031	WI

General Provider Information

NPI Number	:	1023302726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CICEL RENEE YOUNG LPN

Provider Business Mailing Address
First Line	:	2626 WEST CUSTER AVE # 4
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53209
Country	:	US
Telephone Number	:	770-895-5355
Fax Number	:

Provider Business Practice Location Address
First Line	:	2620 W CUSTER AVE
Second Line	:	4
City	:	GLENDALE
State	:	WI
Zip	:	53209-4982
Country	:	US
Telephone Number	:	770-895-5355
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2011
Last Update Date	:	05/31/2011

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