MEDICARE: MRS. GLADYS VERSALLES CNA

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	374U00000X	Home Health Aide	13818	FL

General Provider Information

NPI Number	:	1245255033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GLADYS VERSALLES CNA

Provider Business Mailing Address
First Line	:	795 NW 95TH TER
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33150-1817
Country	:	US
Telephone Number	:	305-864-8323
Fax Number	:	305-377-4815

Provider Business Practice Location Address
First Line	:	7705 ABBOTT AVE
Second Line	:	305
City	:	MIAMI BEACH
State	:	FL
Zip	:	33141-2344
Country	:	US
Telephone Number	:	305-864-8323
Fax Number	:	305-377-4815

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

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	07/08/2007

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