Provider Demographics
NPI:1164777421
Name:ZAMUDIO, ELISE (LVN)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:ZAMUDIO
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 1:1020 S. ARROYO PKWY.
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3214
Mailing Address - Country:US
Mailing Address - Phone:626-403-2794
Mailing Address - Fax:
Practice Address - Street 1:1020 S ARROYO PKWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3214
Practice Address - Country:US
Practice Address - Phone:626-403-2794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 128576101YM0800X
CA101YP1600X
CAVN128576164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral