MEDICARE: MARY WESLEY 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	163WH0200X	Home Health Registered Nurse		WI

General Provider Information

NPI Number	:	1407815186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY WESLEY RN

Provider Business Mailing Address
First Line	:	4522 N 78TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-5306
Country	:	US
Telephone Number	:	414-536-0340
Fax Number	:	414-536-0340

Provider Business Practice Location Address
First Line	:	4522 N 78TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-5306
Country	:	US
Telephone Number	:	414-536-0340
Fax Number	:	414-536-0340

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

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	07/08/2007

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