MEDICARE: MRS. CONNIE RAE SHREVES R.N.

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	163WS0200X	School Registered Nurse	RN1830422	FL

General Provider Information

NPI Number	:	1427247816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CONNIE RAE SHREVES R.N.

Provider Business Mailing Address
First Line	:	221 HOSPITAL DR NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5066
Country	:	US
Telephone Number	:	850-833-9240
Fax Number	:

Provider Business Practice Location Address
First Line	:	8078 4TH ST
Second Line	:
City	:	LAUREL HILL
State	:	FL
Zip	:	32567-2119
Country	:	US
Telephone Number	:	850-652-4111
Fax Number	:	850-652-4659

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

Provider Enumeration Date	:	10/22/2007
Last Update Date	:	02/11/2008

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