MEDICARE: AGING SUCCESSFULLY PC

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	363LG0600X	Gerontology Nurse Practitioner

General Provider Information

NPI Number	:	1952694341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGING SUCCESSFULLY PC

Provider Business Mailing Address
First Line	:	115 SPRING RIDGE DR
Second Line	:
City	:	MURPHY
State	:	TX
Zip	:	75094-4267
Country	:	US
Telephone Number	:	972-384-0694
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 SPRING RIDGE DR
Second Line	:
City	:	MURPHY
State	:	TX
Zip	:	75094-4267
Country	:	US
Telephone Number	:	972-384-0694
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JODY JOHNSON
Credential	:	NP
Telephone Number	:	972-384-0694

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	02/07/2012

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Directions to “AGING SUCCESSFULLY PC ” Practice Location

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