MEDICARE: MRS. CHARLENE POPE WINDSOR 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	163WD0400X	Diabetes Educator Registered Nurse	2005040807	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2005040807	OTHER	MO	LICENSE

General Provider Information

NPI Number	:	1659600781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHARLENE POPE WINDSOR RN

Provider Business Mailing Address
First Line	:	14574 COLORADO RD
Second Line	:
City	:	DIXON
State	:	MO
Zip	:	65459-8262
Country	:	US
Telephone Number	:	573-759-6815
Fax Number	:

Provider Business Practice Location Address
First Line	:	14574 COLORADO RD
Second Line	:
City	:	DIXON
State	:	MO
Zip	:	65459-8262
Country	:	US
Telephone Number	:	573-759-6815
Fax Number	:

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

Provider Enumeration Date	:	12/21/2009
Last Update Date	:	02/10/2020

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