MEDICARE: MRS. JO ELLEN FUENTES LMT

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	174400000X	Specialist	THR-587	KS

General Provider Information

NPI Number	:	1568589398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JO ELLEN FUENTES LMT

Provider Business Mailing Address
First Line	:	8610 STARK AVE
Second Line	:
City	:	RAYTOWN
State	:	MO
Zip	:	64138-3165
Country	:	US
Telephone Number	:	816-529-7307
Fax Number	:

Provider Business Practice Location Address
First Line	:	15238 BROADMOOR ST
Second Line	:
City	:	OVERLAND PARK
State	:	KS
Zip	:	66223-3137
Country	:	US
Telephone Number	:	816-529-7307
Fax Number	:

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

Provider Enumeration Date	:	03/25/2007
Last Update Date	:	07/08/2007

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