MEDICARE: IDA MARY SPEARS RN

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	163WS0200X	School Registered Nurse	RN524882	FL

General Provider Information

NPI Number	:	1093788812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IDA MARY SPEARS RN

Provider Business Mailing Address
First Line	:	1290 GOLFVIEW AVE
Second Line	:
City	:	BARTOW
State	:	FL
Zip	:	33830-6738
Country	:	US
Telephone Number	:	863-519-7900
Fax Number	:	863-519-7696

Provider Business Practice Location Address
First Line	:	115 S OAK AVE
Second Line	:
City	:	FORT MEADE
State	:	FL
Zip	:	33841-3527
Country	:	US
Telephone Number	:	863-519-7900
Fax Number	:	863-519-7696

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

Provider Enumeration Date	:	02/10/2006
Last Update Date	:	07/08/2007

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