MEDICARE: STACY ELLETT 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	2037893	AL

General Provider Information

NPI Number	:	1245542786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY ELLETT LPN

Provider Business Mailing Address
First Line	:	323 CHURCH AVE NE
Second Line	:
City	:	JACKSONVILLE
State	:	AL
Zip	:	36265-1868
Country	:	US
Telephone Number	:	256-365-2374
Fax Number	:

Provider Business Practice Location Address
First Line	:	323 CHURCH AVE NE
Second Line	:
City	:	JACKSONVILLE
State	:	AL
Zip	:	36265-1868
Country	:	US
Telephone Number	:	256-365-2374
Fax Number	:

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

Provider Enumeration Date	:	07/13/2010
Last Update Date	:	07/13/2010

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