MEDICARE: LILLA RAINEY I

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	164W00000X	Licensed Practical Nurse	321047-1	NY

General Provider Information

NPI Number	:	1497144398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILLA RAINEY I

Provider Business Mailing Address
First Line	:	3320 WICKHAM AVE
Second Line	:	3FL
City	:	BRONX
State	:	NY
Zip	:	10469-2736
Country	:	US
Telephone Number	:	347-843-8078
Fax Number	:

Provider Business Practice Location Address
First Line	:	3320 WICKHAM AVE
Second Line	:	3FL
City	:	BRONX
State	:	NY
Zip	:	10469-2736
Country	:	US
Telephone Number	:	347-843-8078
Fax Number	:

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

Provider Enumeration Date	:	01/15/2015
Last Update Date	:	01/15/2015

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Directions to “ LILLA RAINEY I ” Practice Location

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