Provider Demographics
NPI:1033543731
Name:VIDOVICH, ELIZABETH RYAN (LVN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RYAN
Last Name:VIDOVICH
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-1117
Mailing Address - Country:US
Mailing Address - Phone:408-642-5039
Mailing Address - Fax:408-642-5039
Practice Address - Street 1:2540 FOREST AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-1117
Practice Address - Country:US
Practice Address - Phone:408-642-5039
Practice Address - Fax:408-642-5039
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
CAVN230370164W00000X
CAVN203070167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician