MEDICARE: JESSICA JEAN CUNNINGHAM RN, 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	163W00000X	Registered Nurse	R 199450-0	MN
2	164W00000X	Licensed Practical Nurse	L 067912-7	MN

General Provider Information

NPI Number	:	1770889669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA JEAN CUNNINGHAM RN, LPN

Provider Business Mailing Address
First Line	:	30286 FOX RUN RD
Second Line	:
City	:	STACY
State	:	MN
Zip	:	55079-9653
Country	:	US
Telephone Number	:	651-269-3362
Fax Number	:

Provider Business Practice Location Address
First Line	:	30286 FOX RUN RD
Second Line	:
City	:	STACY
State	:	MN
Zip	:	55079-9653
Country	:	US
Telephone Number	:	651-269-3362
Fax Number	:

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

Provider Enumeration Date	:	02/10/2011
Last Update Date	:	02/10/2011

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