MEDICARE: MRS. BRENDA WOOD LPN

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	8158093	NY

General Provider Information

NPI Number	:	1073998688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRENDA WOOD LPN

Provider Business Mailing Address
First Line	:	22 BEYERSDORFER ST
Second Line	:
City	:	KINGSTON
State	:	NY
Zip	:	12401-8605
Country	:	US
Telephone Number	:	845-339-7661
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 BEYERSDORFER ST
Second Line	:
City	:	KINGSTON
State	:	NY
Zip	:	12401-8605
Country	:	US
Telephone Number	:	845-339-7661
Fax Number	:

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

Provider Enumeration Date	:	07/24/2015
Last Update Date	:	07/24/2015

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