MEDICARE: EDWINA PATRICE MACKROY-SNELL M.ED.

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	174400000X	Specialist

General Provider Information

NPI Number	:	1770136137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWINA PATRICE MACKROY-SNELL M.ED.

Provider Business Mailing Address
First Line	:	204 E ST
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33853-3503
Country	:	US
Telephone Number	:	407-212-5501
Fax Number	:

Provider Business Practice Location Address
First Line	:	204 E ST
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33853-3503
Country	:	US
Telephone Number	:	407-212-5501
Fax Number	:

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

Provider Enumeration Date	:	07/24/2019
Last Update Date	:	07/24/2019

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