MEDICARE: ANGELIQUE MAHFOOD R.N.

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	163WP2201X	Ambulatory Care Registered Nurse	117357	MO

General Provider Information

NPI Number	:	1336382969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELIQUE MAHFOOD R.N.

Provider Business Mailing Address
First Line	:	6569 SUSON WOODS DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-4529
Country	:	US
Telephone Number	:	314-962-3464
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 S ELM AVE
Second Line	:
City	:	WEBSTER GROVES
State	:	MO
Zip	:	63119-3845
Country	:	US
Telephone Number	:	314-962-3464
Fax Number	:

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

Provider Enumeration Date	:	04/13/2009
Last Update Date	:	04/13/2009

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