MEDICARE: MRS. BARBIE DIANE WINGET S.H.A.D

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	171W00000X	Contractor	17001135A	IN

General Provider Information

NPI Number	:	1497063366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BARBIE DIANE WINGET S.H.A.D

Provider Business Mailing Address
First Line	:	8219 WICKER AVE
Second Line	:
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-8878
Country	:	US
Telephone Number	:	219-558-0454
Fax Number	:	219-558-0645

Provider Business Practice Location Address
First Line	:	8219 WICKER AVE
Second Line	:
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-8878
Country	:	US
Telephone Number	:	219-558-0454
Fax Number	:	219-558-0645

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

Provider Enumeration Date	:	09/14/2010
Last Update Date	:	09/14/2010

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