MEDICARE: ELLEN THERESA MCGUIRE LICENSED PRACTICAL N

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	164W00000X	Licensed Practical Nurse	191597	NY

General Provider Information

NPI Number	:	1861952681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN THERESA MCGUIRE LICENSED PRACTICAL N

Provider Business Mailing Address
First Line	:	1530 SUNDANCE TRL
Second Line	:
City	:	LAKE VIEW
State	:	NY
Zip	:	14085-9529
Country	:	US
Telephone Number	:	716-627-3964
Fax Number	:

Provider Business Practice Location Address
First Line	:	6855 SOUTHWESTERN BLVD
Second Line	:
City	:	LAKE VIEW
State	:	NY
Zip	:	14085-9642
Country	:	US
Telephone Number	:	716-627-5970
Fax Number	:

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

Provider Enumeration Date	:	03/20/2019
Last Update Date	:	03/20/2019

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