Provider Demographics
NPI:1346442035
Name:UTENDORF, CARLA MAE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:MAE
Last Name:UTENDORF
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12170 RD G-12
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:OH
Mailing Address - Zip Code:45875
Mailing Address - Country:US
Mailing Address - Phone:419-876-3066
Mailing Address - Fax:
Practice Address - Street 1:10129 TWP RD 8
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:OH
Practice Address - Zip Code:45875
Practice Address - Country:US
Practice Address - Phone:419-523-4231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN068301164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2526592OtherPROVIDER NUMBER