MEDICARE: STARICA SHANELL DAVIS 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	2874801	NY

General Provider Information

NPI Number	:	1780955930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STARICA SHANELL DAVIS LPN

Provider Business Mailing Address
First Line	:	25 CROSS GATES RD
Second Line	:
City	:	GATES
State	:	NY
Zip	:	14606-3306
Country	:	US
Telephone Number	:	585-285-9673
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 CROSS GATES RD
Second Line	:
City	:	GATES
State	:	NY
Zip	:	14606-3306
Country	:	US
Telephone Number	:	585-285-9673
Fax Number	:

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

Provider Enumeration Date	:	01/19/2012
Last Update Date	:	01/19/2012

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