MEDICARE: BIRDINE MILDRED-MARIE HERALD 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	0002061023	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0002061023	OTHER	VA	LPN

General Provider Information

NPI Number	:	1457018749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BIRDINE MILDRED-MARIE HERALD LPN

Provider Business Mailing Address
First Line	:	1941 CHARLEY BALLARD RD
Second Line	:
City	:	LINDSIDE
State	:	WV
Zip	:	24951-7360
Country	:	US
Telephone Number	:	304-994-1262
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 ROANOKE ST STE 1
Second Line	:
City	:	CHRISTIANSBURG
State	:	VA
Zip	:	24073-2512
Country	:	US
Telephone Number	:	434-941-6207
Fax Number	:

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

Provider Enumeration Date	:	11/21/2021
Last Update Date	:	11/21/2021

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