MEDICARE: MIKAYLA STANLEY 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	335716-01	NY

General Provider Information

NPI Number	:	1710585518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAYLA STANLEY LPN

Provider Business Mailing Address
First Line	:	6489 STATE ROUTE 104A
Second Line	:
City	:	RED CREEK
State	:	NY
Zip	:	13143-3106
Country	:	US
Telephone Number	:	315-576-5689
Fax Number	:

Provider Business Practice Location Address
First Line	:	6489 STATE ROUTE 104A
Second Line	:
City	:	RED CREEK
State	:	NY
Zip	:	13143-3106
Country	:	US
Telephone Number	:	315-576-5689
Fax Number	:

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

Provider Enumeration Date	:	10/14/2020
Last Update Date	:	10/14/2020

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