MEDICARE: MISS GRACE ELEANOR AMARALI 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	163WC0400X	Case Management Registered Nurse	RN467219	CA
2	171M00000X	Case Manager/Care Coordinator	RVN004520	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RN467219	OTHER	CA	REGISTERED NURSE
2	RVN004520	OTHER	CA	DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1467641142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS GRACE ELEANOR AMARALI RN

Provider Business Mailing Address
First Line	:	2523 WESTBERRY DRIVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-4183
Country	:	US
Telephone Number	:	707-544-4703
Fax Number	:

Provider Business Practice Location Address
First Line	:	2523 WESTBERRY DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-4183
Country	:	US
Telephone Number	:	707-544-4703
Fax Number	:

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

Provider Enumeration Date	:	10/18/2007
Last Update Date	:	10/18/2007

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