MEDICARE: MISS ETTA LEORA HAMMIE LVN

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	171393	TX

General Provider Information

NPI Number	:	1265819916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ETTA LEORA HAMMIE LVN

Provider Business Mailing Address
First Line	:	1012 SKYLINE DR
Second Line	:	APT 1412
City	:	ARLINGTON
State	:	TX
Zip	:	76011-1383
Country	:	US
Telephone Number	:	817-298-9792
Fax Number	:	817-617-3479

Provider Business Practice Location Address
First Line	:	2327 OAKLAND BLVD
Second Line	:
City	:	FT. WORTH
State	:	TX
Zip	:	76011
Country	:	US
Telephone Number	:	817-984-1496
Fax Number	:	817-984-1497

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

Provider Enumeration Date	:	05/01/2015
Last Update Date	:	05/01/2015

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