Healthcare Provider Details

I. General information

NPI: 1972718609
Provider Name (Legal Business Name): JUDITH ELAINE KODAJ R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1092 E GRAND AVE SLO CO. MENTAL HEALTH
ARROYO GRANDE CA
93420-2565
US

IV. Provider business mailing address

511 MORNING RISE LN
ARROYO GRANDE CA
93420-4141
US

V. Phone/Fax

Practice location:
  • Phone: 805-473-7060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number444352
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: