MEDICARE: MS. JENNIFER LYNNE DIZES 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	121004	MO
2	163W00000X	Registered Nurse	041314462	IL

General Provider Information

NPI Number	:	1538329735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER LYNNE DIZES RN

Provider Business Mailing Address
First Line	:	3545 LAFAYETTE AVE
Second Line	:	SALUS CENTER 2ND FLOOR
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1314
Country	:	US
Telephone Number	:	314-977-9339
Fax Number	:	314-977-7529

Provider Business Practice Location Address
First Line	:	3545 LAFAYETTE AVE
Second Line	:	SALUS CENTER 2ND FLOOR
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1314
Country	:	US
Telephone Number	:	314-977-9339
Fax Number	:	314-977-7529

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

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	06/11/2008

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