MEDICARE: MRS. KATHRYN L MOOT 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	20-07-0555	OH

General Provider Information

NPI Number	:	1962464537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHRYN L MOOT LPN

Provider Business Mailing Address
First Line	:	12928 LISBON ST SE
Second Line	:
City	:	PARIS
State	:	OH
Zip	:	44669-9751
Country	:	US
Telephone Number	:	330-862-2493
Fax Number	:

Provider Business Practice Location Address
First Line	:	12928 LISBON STREET SE
Second Line	:
City	:	PARIS
State	:	OH
Zip	:	44669-9751
Country	:	US
Telephone Number	:	330-862-2493
Fax Number	:

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

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	07/08/2007

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