Basic Information
Provider Information | |||||||||
NPI: | 1033275656 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REYNA | ||||||||
FirstName: | ELMA | ||||||||
MiddleName: | ESTELA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LVN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 228 SAINT GEORGE ST | ||||||||
Address2: |   | ||||||||
City: | GONZALES | ||||||||
State: | TX | ||||||||
PostalCode: | 786293910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8306726511 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 228 SAINT GEORGE ST | ||||||||
Address2: |   | ||||||||
City: | GONZALES | ||||||||
State: | TX | ||||||||
PostalCode: | 786293910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8306726511 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 164830 | TX | Y |   | Nursing Service Providers | Licensed Vocational Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 164830 | 01 | TX | VOCATION NURSE LICENSE | OTHER |