MEDICARE: ANGELA N DEGRAW RN

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	580760-1	NY

General Provider Information

NPI Number	:	1457620767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA N DEGRAW RN

Provider Business Mailing Address
First Line	:	239 CAYUGA ST
Second Line	:
City	:	UNION SPRINGS
State	:	NY
Zip	:	13160-3107
Country	:	US
Telephone Number	:	315-889-4128
Fax Number	:	315-889-4133

Provider Business Practice Location Address
First Line	:	239 CAYUGA ST
Second Line	:
City	:	UNION SPRINGS
State	:	NY
Zip	:	13160-3107
Country	:	US
Telephone Number	:	315-889-4128
Fax Number	:	315-889-4133

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

Provider Enumeration Date	:	12/16/2011
Last Update Date	:	12/16/2011

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