MEDICARE: LUCY MARLENA PERKERSON 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	163WA2000X	Administrator Registered Nurse	RN148540	GA

General Provider Information

NPI Number	:	1447518212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCY MARLENA PERKERSON RN

Provider Business Mailing Address
First Line	:	122 GORDON COMMERCIAL DR STE C
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30240-5754
Country	:	US
Telephone Number	:	706-672-1118
Fax Number	:	706-672-1918

Provider Business Practice Location Address
First Line	:	122 GORDON COMMERCIAL DR STE C
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30240-5754
Country	:	US
Telephone Number	:	706-672-1118
Fax Number	:	706-672-1918

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

Provider Enumeration Date	:	04/30/2012
Last Update Date	:	04/30/2012

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