Provider Demographics
NPI:1689095093
Name:SCOTT, MABELL OMOYE (LPN)
Entity Type:Individual
Prefix:
First Name:MABELL
Middle Name:OMOYE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MABELL
Other - Middle Name:OMOYE
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:724 OWL CT
Mailing Address - Street 2:
Mailing Address - City:WOLVERINE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3066
Mailing Address - Country:US
Mailing Address - Phone:313-675-5341
Mailing Address - Fax:
Practice Address - Street 1:724 OWL COURT
Practice Address - Street 2:
Practice Address - City:WOLVERINE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390
Practice Address - Country:US
Practice Address - Phone:313-675-5341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703110100164X00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No251E00000XAgenciesHome Health