=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851635429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MASHALA MONEA RUNYON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2012
-----------------------------------------------------
Last Update Date | 11/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1407 MALLARD
-----------------------------------------------------
City | MAGNOLIA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71753-9710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-562-1931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 615 E MCNEIL
-----------------------------------------------------
City | MAGNOLIA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71753-3061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-949-4544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------