MEDICARE: LENEE POWELL-WILSON RN

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	4704283731	MI

General Provider Information

NPI Number	:	1407112139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LENEE POWELL-WILSON RN

Provider Business Mailing Address
First Line	:	4619 FOX VALLEY DR APT 2A
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-8197
Country	:	US
Telephone Number	:	630-205-6137
Fax Number	:

Provider Business Practice Location Address
First Line	:	4619 FOX VALLEY DR APT 2A
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-8197
Country	:	US
Telephone Number	:	630-205-6137
Fax Number	:

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

Provider Enumeration Date	:	04/06/2012
Last Update Date	:	04/06/2012

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