MEDICARE: MRS. CRYSTAL ANN WONDERLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	172A00000X	Driver
2	3747P1801X	Personal Care Attendant
3	376J00000X	Homemaker

General Provider Information

NPI Number	:	1740951292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL ANN WONDERLY

Provider Business Mailing Address
First Line	:	707 W PARK DR
Second Line	:
City	:	FOSTORIA
State	:	OH
Zip	:	44830-1664
Country	:	US
Telephone Number	:	419-619-2799
Fax Number	:

Provider Business Practice Location Address
First Line	:	707 W PARK DR
Second Line	:
City	:	FOSTORIA
State	:	OH
Zip	:	44830-1664
Country	:	US
Telephone Number	:	419-619-2799
Fax Number	:

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

Provider Enumeration Date	:	09/24/2021
Last Update Date	:	09/24/2021

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