MEDICARE: SHARAE GWENDOLYN MASSEY LPN

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	286091	NY

General Provider Information

NPI Number	:	1508154535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHARAE GWENDOLYN MASSEY LPN

Provider Business Mailing Address
First Line	:	1 MARIGOLD ST
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14615-3626
Country	:	US
Telephone Number	:	585-309-5650
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 MARIGOLD ST
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14615-3626
Country	:	US
Telephone Number	:	585-309-5650
Fax Number	:

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

Provider Enumeration Date	:	07/12/2011
Last Update Date	:	07/12/2011

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