MEDICARE: CARREN NYASUGUTA STRATFORD LVN

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	347C00000X	Private Vehicle
2	347C00000X	Private Vehicle		TX

General Provider Information

NPI Number	:	1700122892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARREN NYASUGUTA STRATFORD LVN

Provider Business Mailing Address
First Line	:	3840 FOXHOUND LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2589
Country	:	US
Telephone Number	:	817-501-1103
Fax Number	:

Provider Business Practice Location Address
First Line	:	3840 FOXHOUND LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2589
Country	:	US
Telephone Number	:	817-501-1103
Fax Number	:

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

Provider Enumeration Date	:	12/18/2012
Last Update Date	:	12/18/2012

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