MEDICARE: MS. WILLIEMAE OGLETREE LICENSED PRACTICAL N

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	PN131109-M-IV	OH

General Provider Information

NPI Number	:	1639471782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. WILLIEMAE OGLETREE LICENSED PRACTICAL N

Provider Business Mailing Address
First Line	:	12908 CHRISTINE AVENUE
Second Line	:
City	:	GARFIELD HEIGHTS
State	:	OH
Zip	:	44105
Country	:	US
Telephone Number	:	216-404-9195
Fax Number	:

Provider Business Practice Location Address
First Line	:	12908 CHRISTINE AVENUE
Second Line	:
City	:	GARFIELD HEIGHTS
State	:	OH
Zip	:	44105
Country	:	US
Telephone Number	:	216-404-9195
Fax Number	:

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

Provider Enumeration Date	:	11/23/2010
Last Update Date	:	11/23/2010

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