MEDICARE: MS. PAMELA LYNNE WILDERMUTH 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	311ZA0620X	Adult Care Home Facility	PN110992	OH

General Provider Information

NPI Number	:	1629085469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PAMELA LYNNE WILDERMUTH LPN

Provider Business Mailing Address
First Line	:	4227 SESTOS DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43207-8423
Country	:	US
Telephone Number	:	614-497-8149
Fax Number	:

Provider Business Practice Location Address
First Line	:	4227 SESTOS DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43207-8423
Country	:	US
Telephone Number	:	614-497-8149
Fax Number	:

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/08/2007

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