MEDICARE: MRS. ANTOINETTE SPENCER 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	PN104567	OH

General Provider Information

NPI Number	:	1265761803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANTOINETTE SPENCER LPN

Provider Business Mailing Address
First Line	:	14425 ONAWAY RD
Second Line	:
City	:	SHAKER HEIGHTS
State	:	OH
Zip	:	44120-2840
Country	:	US
Telephone Number	:	216-559-0856
Fax Number	:

Provider Business Practice Location Address
First Line	:	14425 ONAWAY RD
Second Line	:
City	:	SHAKER HEIGHTS
State	:	OH
Zip	:	44120-2840
Country	:	US
Telephone Number	:	216-559-0856
Fax Number	:

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

Provider Enumeration Date	:	12/10/2009
Last Update Date	:	12/10/2009

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