Provider Demographics
NPI:1811231780
Name:SUDBURY PELHAM, ELIZABETH (LPN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SUDBURY PELHAM
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:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-0635
Mailing Address - Country:US
Mailing Address - Phone:405-238-7311
Mailing Address - Fax:405-238-3530
Practice Address - Street 1:109 S WILLOW ST
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-3833
Practice Address - Country:US
Practice Address - Phone:405-238-7311
Practice Address - Fax:405-238-3530
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13611164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse