1568899854 NPI number — LIDIA ELYSE WIEDOWER RN BSN MS LPC

Table of content: LIDIA ELYSE WIEDOWER RN BSN MS LPC (NPI 1568899854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568899854 NPI number — LIDIA ELYSE WIEDOWER RN BSN MS LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIEDOWER
Provider First Name:
LIDIA
Provider Middle Name:
ELYSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN BSN MS LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STOWE
Provider Other First Name:
LIDIA
Provider Other Middle Name:
ELYSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN BSN MS LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568899854
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 MANN ST
Provider Second Line Business Mailing Address:
STE. 800
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78401-2046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-814-2001
Provider Business Mailing Address Fax Number:
361-814-6502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 MANN ST
Provider Second Line Business Practice Location Address:
STE. 800
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78401-2046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-814-2001
Provider Business Practice Location Address Fax Number:
361-814-6502
Provider Enumeration Date:
10/01/2013

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: 101YP2500X , with the licence number:  62971 , 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)





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