MEDICARE: JEANIE MARIE STAKES

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	578467	TX

General Provider Information

NPI Number	:	1841793304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANIE MARIE STAKES

Provider Business Mailing Address
First Line	:	2802 FOX CREEK TRL
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-7960
Country	:	US
Telephone Number	:	817-475-0341
Fax Number	:

Provider Business Practice Location Address
First Line	:	2802 FOX CREEK TRL
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-7960
Country	:	US
Telephone Number	:	817-475-0341
Fax Number	:

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

Provider Enumeration Date	:	03/12/2018
Last Update Date	:	03/17/2018

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Directions to “ JEANIE MARIE STAKES ” Practice Location

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