MEDICARE: MR. WALTER BRODIE RN BSN

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	163WS0200X	School Registered Nurse	RN 00085749	WA

General Provider Information

NPI Number	:	1831434406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WALTER BRODIE RN BSN

Provider Business Mailing Address
First Line	:	1514 S LAVENTURE RD
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-6034
Country	:	US
Telephone Number	:	360-428-6125
Fax Number	:	360-428-6164

Provider Business Practice Location Address
First Line	:	1514 S LAVENTURE RD
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-6034
Country	:	US
Telephone Number	:	360-428-6125
Fax Number	:	360-428-6164

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

Provider Enumeration Date	:	12/07/2012
Last Update Date	:	12/07/2012

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