MEDICARE: AJA RENEE STILLWATER LVN

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	164X00000X	Licensed Vocational Nurse	341032	TX

General Provider Information

NPI Number	:	1023578168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AJA RENEE STILLWATER LVN

Provider Business Mailing Address
First Line	:	5151 OVERPOOL ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-3647
Country	:	US
Telephone Number	:	210-502-3526
Fax Number	:

Provider Business Practice Location Address
First Line	:	5151 OVERPOOL ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-3647
Country	:	US
Telephone Number	:	210-502-3526
Fax Number	:

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

Provider Enumeration Date	:	03/24/2019
Last Update Date	:	03/24/2019

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