MEDICARE: MRS. THERESA DEANN O'LEARY 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	LP00059871	WA

General Provider Information

NPI Number	:	1134464084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA DEANN O'LEARY LPN

Provider Business Mailing Address
First Line	:	6216 119TH AVE E
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98372-2825
Country	:	US
Telephone Number	:	253-268-0808
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 26TH AVE SE
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98374-1349
Country	:	US
Telephone Number	:	253-841-8746
Fax Number	:

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

Provider Enumeration Date	:	12/04/2012
Last Update Date	:	12/04/2012

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