=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376905851
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE RENEE STORY LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2016
-----------------------------------------------------
Last Update Date | 03/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20921 HAULOVER CV. #F6
-----------------------------------------------------
City | LUTZ
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-312-5399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20921 HAULOVER CV. #F6
-----------------------------------------------------
City | LUTZ
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-312-5399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number | PN5202601
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------