Provider Demographics
NPI:1609410653
Name:CENTINEO, IDA (RN)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:CENTINEO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 MEDICAL PLAZA DR STE 520
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3204
Mailing Address - Country:US
Mailing Address - Phone:832-562-3974
Mailing Address - Fax:832-663-9378
Practice Address - Street 1:920 MEDICAL PLAZA DR STE 520
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-3204
Practice Address - Country:US
Practice Address - Phone:832-562-3974
Practice Address - Fax:832-663-9378
Is Sole Proprietor?:No
Enumeration Date:2019-11-02
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01038600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily