MEDICARE: ANGELINA WYATT-JOLLY 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	218332	WI

General Provider Information

NPI Number	:	1407203219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELINA WYATT-JOLLY RN

Provider Business Mailing Address
First Line	:	PO BOX 76120
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-7720
Country	:	US
Telephone Number	:	414-399-0134
Fax Number	:

Provider Business Practice Location Address
First Line	:	3124 N 50TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-3210
Country	:	US
Telephone Number	:	414-399-0134
Fax Number	:

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

Provider Enumeration Date	:	05/21/2016
Last Update Date	:	05/21/2016

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