MEDICARE: LACIE JAI ANDERSON 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	60670	OK

General Provider Information

NPI Number	:	1629547948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACIE JAI ANDERSON LPN

Provider Business Mailing Address
First Line	:	6721 NW 124TH TER
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73142-3124
Country	:	US
Telephone Number	:	405-201-0322
Fax Number	:

Provider Business Practice Location Address
First Line	:	6721 NW 124TH TER
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73142-3124
Country	:	US
Telephone Number	:	405-201-0322
Fax Number	:

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

Provider Enumeration Date	:	11/15/2018
Last Update Date	:	11/15/2018

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