MEDICARE: AMY M WOLLET 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	PN.138492-M-IV	OH

General Provider Information

NPI Number	:	1831581149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY M WOLLET LPN

Provider Business Mailing Address
First Line	:	12523 N PALMYRA RD
Second Line	:
City	:	NORTH JACKSON
State	:	OH
Zip	:	44451-9727
Country	:	US
Telephone Number	:	330-397-6166
Fax Number	:

Provider Business Practice Location Address
First Line	:	12523 N PALMYRA RD
Second Line	:
City	:	NORTH JACKSON
State	:	OH
Zip	:	44451-9727
Country	:	US
Telephone Number	:	330-397-6166
Fax Number	:

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

Provider Enumeration Date	:	02/23/2015
Last Update Date	:	02/23/2015

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