MEDICARE: MS. PATRICIA K THEODAT 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	309961	NY

General Provider Information

NPI Number	:	1619239878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PATRICIA K THEODAT LPN

Provider Business Mailing Address
First Line	:	1207 E 99TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-5028
Country	:	US
Telephone Number	:	347-701-0262
Fax Number	:

Provider Business Practice Location Address
First Line	:	1160 OCEAN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-1976
Country	:	US
Telephone Number	:	347-701-0262
Fax Number	:

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

Provider Enumeration Date	:	06/13/2012
Last Update Date	:	06/13/2012

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