MEDICARE: SELF-EMPLOYED NP DEVELOPMENT CO., LLC

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	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1588832356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELF-EMPLOYED NP DEVELOPMENT CO., LLC

Provider Business Mailing Address
First Line	:	PO BOX 30780
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43230-0780
Country	:	US
Telephone Number	:	614-476-6931
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 N STYGLER RD
Second Line	:
City	:	GAHANNA
State	:	OH
Zip	:	43230-2437
Country	:	US
Telephone Number	:	614-476-6931
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. REBECCA SHAW
Credential	:
Telephone Number	:	614-476-6931

Provider Enumeration Date	:	02/14/2008
Last Update Date	:	04/20/2012

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