MEDICARE: MRS. CLARISSA CALDWELL

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	374U00000X	Home Health Aide	201815234	AL

General Provider Information

NPI Number	:	1518436260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CLARISSA CALDWELL

Provider Business Mailing Address
First Line	:	5600 CARMICHAEL RD APT 2207
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-1813
Country	:	US
Telephone Number	:	334-777-7294
Fax Number	:

Provider Business Practice Location Address
First Line	:	5600 CARMICHAEL RD APT 2207
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-1813
Country	:	US
Telephone Number	:	334-777-7294
Fax Number	:

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

Provider Enumeration Date	:	11/23/2018
Last Update Date	:	01/08/2019

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