MEDICARE: MISS MARIE SHELLE BAKER RN

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	163W00000X	Registered Nurse	165169-30	WI

General Provider Information

NPI Number	:	1104902576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARIE SHELLE BAKER RN

Provider Business Mailing Address
First Line	:	2894 S 33RD ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-5203
Country	:	US
Telephone Number	:	414-460-2198
Fax Number	:	414-460-2198

Provider Business Practice Location Address
First Line	:	2894 S 33RD ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-5203
Country	:	US
Telephone Number	:	414-460-2198
Fax Number	:	414-460-2198

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

Provider Enumeration Date	:	10/28/2006
Last Update Date	:	10/28/2011

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