MEDICARE: JERI HAYDEN 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	163WD0400X	Diabetes Educator Registered Nurse	1141468	KY

General Provider Information

NPI Number	:	1114420577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERI HAYDEN RN

Provider Business Mailing Address
First Line	:	739 HEYWOOD AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40208-1221
Country	:	US
Telephone Number	:	502-235-5904
Fax Number	:

Provider Business Practice Location Address
First Line	:	739 HEYWOOD AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40208-1221
Country	:	US
Telephone Number	:	502-235-5904
Fax Number	:

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

Provider Enumeration Date	:	03/13/2018
Last Update Date	:	03/13/2018

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