MEDICARE: MRS. RENEE TERESA STICKELMAN RN

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	0001165264	VA

General Provider Information

NPI Number	:	1922000454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RENEE TERESA STICKELMAN RN

Provider Business Mailing Address
First Line	:	309 OLD DARBY LN
Second Line	:
City	:	WINTHROP HARBOR
State	:	IL
Zip	:	60096-2009
Country	:	US
Telephone Number	:	847-731-9951
Fax Number	:

Provider Business Practice Location Address
First Line	:	309 OLD DARBY LN
Second Line	:
City	:	WINTHROP HARBOR
State	:	IL
Zip	:	60096-2009
Country	:	US
Telephone Number	:	847-731-9951
Fax Number	:

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	07/08/2007

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