Provider Demographics
NPI:1659083723
Name:TELLO FLORES, GRACIELA (LPN)
Entity Type:Individual
Prefix:
First Name:GRACIELA
Middle Name:
Last Name:TELLO FLORES
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 1:939 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3608
Mailing Address - Country:US
Mailing Address - Phone:316-263-8807
Mailing Address - Fax:
Practice Address - Street 1:939 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3608
Practice Address - Country:US
Practice Address - Phone:316-263-8807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS50961164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse