MEDICARE: MRS. JELLISA JUANA SCOTT STNA

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	376K00000X	Nurse's Aide	400289301003	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	400289301003	OTHER	OH	OHIO DEPT OF HEALTH

General Provider Information

NPI Number	:	1659457729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JELLISA JUANA SCOTT STNA

Provider Business Mailing Address
First Line	:	3920 BRUMBAUGH BLVD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45416-1545
Country	:	US
Telephone Number	:	937-559-8052
Fax Number	:

Provider Business Practice Location Address
First Line	:	3920 BRUMBAUGH BLVD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45416-1545
Country	:	US
Telephone Number	:	937-559-8052
Fax Number	:

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

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	07/08/2007

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