MEDICARE: KACELLA MILLS 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	726789	NY

General Provider Information

NPI Number	:	1114496213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KACELLA MILLS RN

Provider Business Mailing Address
First Line	:	1509 BRENTWOOD RD
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-3230
Country	:	US
Telephone Number	:	754-422-4494
Fax Number	:

Provider Business Practice Location Address
First Line	:	1509 BRENTWOOD RD
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-3230
Country	:	US
Telephone Number	:	754-422-4494
Fax Number	:

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

Provider Enumeration Date	:	11/19/2018
Last Update Date	:	11/19/2018

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