MEDICARE: MS. ROBIN MANDEVILLE 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	121516	OH

General Provider Information

NPI Number	:	1760742365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ROBIN MANDEVILLE LPN

Provider Business Mailing Address
First Line	:	3059 REMINGTON RIDGE RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-5670
Country	:	US
Telephone Number	:	614-424-0895
Fax Number	:

Provider Business Practice Location Address
First Line	:	3059 REMINGTON RIDGE RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-5670
Country	:	US
Telephone Number	:	614-424-0895
Fax Number	:

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

Provider Enumeration Date	:	05/17/2012
Last Update Date	:	05/17/2012

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