MEDICARE: LACHELLE WITHERSPOON RN

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	163W00000X	Registered Nurse	543482	CA

General Provider Information

NPI Number	:	1720261522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACHELLE WITHERSPOON RN

Provider Business Mailing Address
First Line	:	2647 INTERNATIONAL BLVD
Second Line	:	600
City	:	OAKLAND
State	:	CA
Zip	:	94601-1537
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2647 INTERNATIONAL BLVD
Second Line	:	600
City	:	OAKLAND
State	:	CA
Zip	:	94601-1537
Country	:	US
Telephone Number	:	510-434-7879
Fax Number	:	510-434-7908

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

Provider Enumeration Date	:	12/14/2007
Last Update Date	:	12/14/2007

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