MEDICARE: YACHIRA MARIE SEGARRA 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	PN5253036	FL

General Provider Information

NPI Number	:	1033803804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YACHIRA MARIE SEGARRA LPN

Provider Business Mailing Address
First Line	:	4891 LAKE RIDGE RD
Second Line	:
City	:	CHIPLEY
State	:	FL
Zip	:	32428-3680
Country	:	US
Telephone Number	:	808-428-6496
Fax Number	:

Provider Business Practice Location Address
First Line	:	4891 LAKE RIDGE RD
Second Line	:
City	:	CHIPLEY
State	:	FL
Zip	:	32428-3680
Country	:	US
Telephone Number	:	808-428-6496
Fax Number	:

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

Provider Enumeration Date	:	06/05/2023
Last Update Date	:	06/05/2023

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