MEDICARE: FANTAZIA M EDICK 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	10-311923	NY

General Provider Information

NPI Number	:	1174875082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FANTAZIA M EDICK LPN

Provider Business Mailing Address
First Line	:	614 CLAY AVE
Second Line	:	2
City	:	ROCHESTER
State	:	NY
Zip	:	14613-1030
Country	:	US
Telephone Number	:	585-478-0048
Fax Number	:

Provider Business Practice Location Address
First Line	:	614 CLAY AVE
Second Line	:	2
City	:	ROCHESTER
State	:	NY
Zip	:	14613-1030
Country	:	US
Telephone Number	:	585-478-0048
Fax Number	:

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

Provider Enumeration Date	:	10/03/2012
Last Update Date	:	10/03/2012

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