MEDICARE: MRS. WILLIE RUTH BOYD LICENSE PRACTICAL NU

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	PN030364	OH

General Provider Information

NPI Number	:	1518171990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. WILLIE RUTH BOYD LICENSE PRACTICAL NU

Provider Business Mailing Address
First Line	:	5292 BIG BEND DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45427
Country	:	US
Telephone Number	:	937-268-9304
Fax Number	:	937-268-9304

Provider Business Practice Location Address
First Line	:	5292 BIG BEND DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45427
Country	:	US
Telephone Number	:	937-268-9304
Fax Number	:	937-268-9304

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

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/08/2007

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