MEDICARE: MRS. NYLA GRACE QUINN OTR

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	225XP0200X	Pediatric Occupational Therapist	109702	TX

General Provider Information

NPI Number	:	1356477418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NYLA GRACE QUINN OTR

Provider Business Mailing Address
First Line	:	1105 AVENUE D
Second Line	:
City	:	MARBLE FALLS
State	:	TX
Zip	:	78654-5221
Country	:	US
Telephone Number	:	830-693-1113
Fax Number	:	830-693-1113

Provider Business Practice Location Address
First Line	:	1105 AVENUE D
Second Line	:
City	:	MARBLE FALLS
State	:	TX
Zip	:	78654-5221
Country	:	US
Telephone Number	:	830-693-1113
Fax Number	:	830-693-1113

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

Provider Enumeration Date	:	02/25/2007
Last Update Date	:	07/08/2007

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