MEDICARE: MISS COZETTA C FUDGE SOLE CARE PROVIDER

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	3747A0650X	Attendant Care Provider	G01174212	NE

General Provider Information

NPI Number	:	1841180429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS COZETTA C FUDGE SOLE CARE PROVIDER

Provider Business Mailing Address
First Line	:	4672 NEBRASKA AVE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68104-1467
Country	:	US
Telephone Number	:	402-312-7934
Fax Number	:

Provider Business Practice Location Address
First Line	:	4672 NEBRASKA AVE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68104-1467
Country	:	US
Telephone Number	:	402-312-7934
Fax Number	:

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

Provider Enumeration Date	:	07/07/2025
Last Update Date	:	07/07/2025

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