MEDICARE: AMY PAUL BSN, RN, IBCLC

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	200342091RN	OR
2	163WL0100X	Lactation Consultant (Registered Nurse)	L-68502	OR

General Provider Information

NPI Number	:	1265818702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY PAUL BSN, RN, IBCLC

Provider Business Mailing Address
First Line	:	16 FAIRVIEW HEIGHTS LOOP
Second Line	:
City	:	BURNS
State	:	OR
Zip	:	97720-2324
Country	:	US
Telephone Number	:	503-724-7654
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 FAIRVIEW HEIGHTS LOOP
Second Line	:
City	:	BURNS
State	:	OR
Zip	:	97720-2324
Country	:	US
Telephone Number	:	503-724-7654
Fax Number	:

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

Provider Enumeration Date	:	08/06/2015
Last Update Date	:	08/06/2015

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