MEDICARE: JENNIFER DIANE BAKER 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	163W00000X	Registered Nurse	211434	TN

General Provider Information

NPI Number	:	1477012904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER DIANE BAKER RN

Provider Business Mailing Address
First Line	:	6269 S NOPONE VALLEY RD
Second Line	:
City	:	DECATUR
State	:	TN
Zip	:	37322-5621
Country	:	US
Telephone Number	:	419-260-1198
Fax Number	:

Provider Business Practice Location Address
First Line	:	6269 S NOPONE VALLEY RD
Second Line	:
City	:	DECATUR
State	:	TN
Zip	:	37322-5621
Country	:	US
Telephone Number	:	419-260-1198
Fax Number	:

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

Provider Enumeration Date	:	03/14/2019
Last Update Date	:	03/14/2019

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