MEDICARE: SONJA LYNN DOUGLAS 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	PN109048	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750391892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SONJA LYNN DOUGLAS LPN

Provider Business Mailing Address
First Line	:	PO BOX 384
Second Line	:
City	:	BEACH CITY
State	:	OH
Zip	:	44608-0384
Country	:	US
Telephone Number	:	330-756-2091
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 N CHURCH
Second Line	:
City	:	BEACH CITY
State	:	OH
Zip	:	44608-0384
Country	:	US
Telephone Number	:	330-756-2091
Fax Number	:

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	07/09/2007

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