MEDICARE: MS. DELORIS NEVELS 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	P304139	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00770393	OTHER	MS	PROVIDER NO.

General Provider Information

NPI Number	:	1760694178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DELORIS NEVELS LPN

Provider Business Mailing Address
First Line	:	2109 VALLEY OF THE MOON RD
Second Line	:	P.O. BOX 246
City	:	HERMANVILLE
State	:	MS
Zip	:	39086-9560
Country	:	US
Telephone Number	:	601-535-2159
Fax Number	:	601-535-2159

Provider Business Practice Location Address
First Line	:	2109 VALLEY OF THE MOON RD
Second Line	:
City	:	HERMANVILLE
State	:	MS
Zip	:	39086-9560
Country	:	US
Telephone Number	:	601-535-2159
Fax Number	:	601-535-2159

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

Provider Enumeration Date	:	05/06/2007
Last Update Date	:	07/08/2007

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