MEDICARE: MS. MARJORIE SUE EATON 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	115934	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5708756	OTHER	OH	OHIO I/O WAIVER

General Provider Information

NPI Number	:	1568735025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARJORIE SUE EATON LPN

Provider Business Mailing Address
First Line	:	2504 LITTLE YORK RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-1630
Country	:	US
Telephone Number	:	937-478-1302
Fax Number	:	937-454-0667

Provider Business Practice Location Address
First Line	:	2504 LITTLE YORK RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-1630
Country	:	US
Telephone Number	:	937-478-1302
Fax Number	:	937-454-0667

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

Provider Enumeration Date	:	02/14/2012
Last Update Date	:	02/14/2012

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