MEDICARE: MR. ANGELIA LYNETTA WILSON-ROBINSON 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	163WE0003X	Emergency Registered Nurse	595911	CA
2	163WE0003X	Emergency Registered Nurse	144341	GA
3	163WE0003X	Emergency Registered Nurse	765282	TX

General Provider Information

NPI Number	:	1487885729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANGELIA LYNETTA WILSON-ROBINSON RN

Provider Business Mailing Address
First Line	:	4323 EAGLE ROCK BLVD
Second Line	:	APT 423
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-3291
Country	:	US
Telephone Number	:	323-219-4936
Fax Number	:	123-456-7890

Provider Business Practice Location Address
First Line	:	4323 EAGLE ROCK BLVD
Second Line	:	APT 423
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-3291
Country	:	US
Telephone Number	:	323-219-4936
Fax Number	:	123-456-7890

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

Provider Enumeration Date	:	08/04/2009
Last Update Date	:	08/04/2009

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