Provider Demographics
NPI:1427535756
Name:UDOR, UTIBEABASI P (LVN)
Entity Type:Individual
Prefix:
First Name:UTIBEABASI
Middle Name:P
Last Name:UDOR
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 1:2504 SAN EFRAIN
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-3846
Mailing Address - Country:US
Mailing Address - Phone:956-566-8881
Mailing Address - Fax:
Practice Address - Street 1:2102 W TEEGE AVE
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-4667
Practice Address - Country:US
Practice Address - Phone:956-412-3337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX300443164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1790847531Medicaid