MEDICARE: JAN MARY MEAD FNP

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	363LF0000X	Family Nurse Practitioner	F332612-1	NY

General Provider Information

NPI Number	:	1730488321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAN MARY MEAD FNP

Provider Business Mailing Address
First Line	:	5697 LAKE RD
Second Line	:
City	:	TULLY
State	:	NY
Zip	:	13159-9412
Country	:	US
Telephone Number	:	315-391-8141
Fax Number	:

Provider Business Practice Location Address
First Line	:	5697 LAKE RD
Second Line	:
City	:	TULLY
State	:	NY
Zip	:	13159-9412
Country	:	US
Telephone Number	:	315-391-8141
Fax Number	:

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

Provider Enumeration Date	:	03/22/2011
Last Update Date	:	03/22/2011

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