MEDICARE: MS. NICOLE MONIQUE ANDERSON LPN

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	121290	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	121290	OTHER		OHIO BOARD OF NURSING

General Provider Information

NPI Number	:	1356657068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NICOLE MONIQUE ANDERSON LPN

Provider Business Mailing Address
First Line	:	10921 GRANTWOOD AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-3626
Country	:	US
Telephone Number	:	216-527-8155
Fax Number	:

Provider Business Practice Location Address
First Line	:	10921 GRANTWOOD AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-3626
Country	:	US
Telephone Number	:	216-527-8155
Fax Number	:

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

Provider Enumeration Date	:	08/19/2010
Last Update Date	:	08/19/2010

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