MEDICARE: GWEN M MAVIS 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	16W00000X	MO

General Provider Information

NPI Number	:	1588063416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWEN M MAVIS LPN

Provider Business Mailing Address
First Line	:	14223 HIGHWAY U
Second Line	:
City	:	ODESSA
State	:	MO
Zip	:	64076-6467
Country	:	US
Telephone Number	:	608-343-8808
Fax Number	:

Provider Business Practice Location Address
First Line	:	819 S BUS HWY 13
Second Line	:
City	:	LEXINGTON
State	:	MO
Zip	:	64067-1515
Country	:	US
Telephone Number	:	660-259-3898
Fax Number	:

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

Provider Enumeration Date	:	08/15/2014
Last Update Date	:	08/15/2014

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