Provider Demographics
NPI:1619200409
Name:GUIDRY, ITINA
Entity Type:Individual
Prefix:
First Name:ITINA
Middle Name:
Last Name:GUIDRY
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 1:614 SHADY DALE DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-5925
Mailing Address - Country:US
Mailing Address - Phone:832-276-9238
Mailing Address - Fax:
Practice Address - Street 1:15011 MONRAD DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77053-1344
Practice Address - Country:US
Practice Address - Phone:832-276-9238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 172V00000X
TX165268246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171W00000XOther Service ProvidersContractor
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory