MEDICARE: MRS. CASSANDRA DAWN HUMPHREY 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	163W00000X	Registered Nurse	RN193231	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	:	1174660369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CASSANDRA DAWN HUMPHREY RN

Provider Business Mailing Address
First Line	:	593 TOWNSHIP ROAD 147
Second Line	:
City	:	KITTS HILL
State	:	OH
Zip	:	45645-8836
Country	:	US
Telephone Number	:	740-643-2840
Fax Number	:

Provider Business Practice Location Address
First Line	:	593 TOWNSHIP ROAD 147
Second Line	:
City	:	KITTS HILL
State	:	OH
Zip	:	45645-8836
Country	:	US
Telephone Number	:	740-643-2840
Fax Number	:

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/08/2007

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