1386052397 NPI number — MS. JENNIFER PULIDO STICE NP

Table of content: MS. JENNIFER PULIDO STICE NP (NPI 1386052397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386052397 NPI number — MS. JENNIFER PULIDO STICE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STICE
Provider First Name:
JENNIFER
Provider Middle Name:
PULIDO
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386052397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13725 NORTHWEST BLVD
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78410-5124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-387-9413
Provider Business Mailing Address Fax Number:
361-387-9616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13725 NORTHWEST BLVD
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78410-5127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-387-9413
Provider Business Practice Location Address Fax Number:
361-387-9616
Provider Enumeration Date:
07/23/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP125868 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 338049501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 361608YLPS . This is a "WELLMED PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".