MEDICARE: KELLI LANSHAW

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1043491285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI LANSHAW

Provider Business Mailing Address
First Line	:	207 W SOUTH ST
Second Line	:
City	:	BISHOP
State	:	CA
Zip	:	93514-3407
Country	:	US
Telephone Number	:	760-873-5895
Fax Number	:	760-873-8835

Provider Business Practice Location Address
First Line	:	207 W SOUTH ST
Second Line	:
City	:	BISHOP
State	:	CA
Zip	:	93514-3407
Country	:	US
Telephone Number	:	760-873-5895
Fax Number	:	760-873-8835

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

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	11/15/2007

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