Provider Demographics
NPI:1134620644
Name:PORTILLO, IRMA (LVN)
Entity type:Individual
Prefix:
First Name:IRMA
Middle Name:
Last Name:PORTILLO
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 1:16803 S LIGHTHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:TX
Mailing Address - Zip Code:77532-4532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16803 S LIGHTHOUSE DR
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:TX
Practice Address - Zip Code:77532-4532
Practice Address - Country:US
Practice Address - Phone:713-299-8393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX187916164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse