MEDICARE: MS. THEODORA LANE VAILE N.P.

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	363LF0000X	Family Nurse Practitioner	RNO77746	GA

General Provider Information

NPI Number	:	1205163797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. THEODORA LANE VAILE N.P.

Provider Business Mailing Address
First Line	:	325 CANDLER RD SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30317-3433
Country	:	US
Telephone Number	:	404-288-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 CANDLER RD SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30317-3433
Country	:	US
Telephone Number	:	404-288-2273
Fax Number	:

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

Provider Enumeration Date	:	11/04/2009
Last Update Date	:	11/04/2009

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