MEDICARE: MRS. TERESA AULT 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	LPO12522	AZ

General Provider Information

NPI Number	:	1568870954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERESA AULT LPN

Provider Business Mailing Address
First Line	:	4315 N MARYVALE PKWY
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85031-1942
Country	:	US
Telephone Number	:	623-691-1715
Fax Number	:	623-691-1720

Provider Business Practice Location Address
First Line	:	4315 N MARYVALE PKWY
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85031-1942
Country	:	US
Telephone Number	:	623-691-1715
Fax Number	:	623-691-1720

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

Provider Enumeration Date	:	07/29/2014
Last Update Date	:	07/29/2014

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