MEDICARE: MRS. BUKOLA WRIGHT

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	224Z00000X	Occupational Therapy Assistant	OTA11395	FL

General Provider Information

NPI Number	:	1194095877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BUKOLA WRIGHT

Provider Business Mailing Address
First Line	:	17 PINE ASH LN
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-7059
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	17 PINE ASH LN
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-7059
Country	:	US
Telephone Number	:	386-283-0565
Fax Number	:

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

Provider Enumeration Date	:	01/11/2012
Last Update Date	:	01/11/2012

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