MEDICARE: DALISSE HUMPHREY RN, BSN

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	163W00000X	Registered Nurse	RN. 313216	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023146362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALISSE HUMPHREY RN, BSN

Provider Business Mailing Address
First Line	:	PO BOX 340093
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45434-0093
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2760 AIRPORT DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43219-2284
Country	:	US
Telephone Number	:	937-286-7490
Fax Number	:

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

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	11/02/2010

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