Provider Demographics
NPI:1215565254
Name:IDJAGBORO, GEORGINA
Entity Type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:IDJAGBORO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 DAIRY ASHFORD RD STE 560
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-3035
Mailing Address - Country:US
Mailing Address - Phone:713-799-2200
Mailing Address - Fax:
Practice Address - Street 1:19400 W BELLFORT ST APT 5304
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-8215
Practice Address - Country:US
Practice Address - Phone:713-922-2746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX350268164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse