MEDICARE: MABELL OMOYE SCOTT 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	164X00000X	Licensed Vocational Nurse	4703110100	MI
2	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1689095093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MABELL OMOYE SCOTT LPN

Provider Business Mailing Address
First Line	:	724 OWL CT
Second Line	:
City	:	WOLVERINE LAKE
State	:	MI
Zip	:	48390-3066
Country	:	US
Telephone Number	:	313-675-5341
Fax Number	:

Provider Business Practice Location Address
First Line	:	724 OWL COURT
Second Line	:
City	:	WOLVERINE LAKE
State	:	MI
Zip	:	48390
Country	:	US
Telephone Number	:	313-675-5341
Fax Number	:

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

Provider Enumeration Date	:	01/02/2014
Last Update Date	:	01/02/2014

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