MEDICARE: MS. VICKI LORAYNE SELLNER O.T.R.

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	225X00000X	Occupational Therapist	OT3443	FL

General Provider Information

NPI Number	:	1447374111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VICKI LORAYNE SELLNER O.T.R.

Provider Business Mailing Address
First Line	:	60 COMARES AVE
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32080-3789
Country	:	US
Telephone Number	:	904-824-1265
Fax Number	:	904-827-1189

Provider Business Practice Location Address
First Line	:	6561 SAN JUAN AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-2857
Country	:	US
Telephone Number	:	904-695-9605
Fax Number	:

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

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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