Healthcare Provider Details

I. General information

NPI: 1548741879
Provider Name (Legal Business Name): OLIVIA XIMENIA CAUDLE LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 COLLEGE MAIN ST APT 16
BRYAN TX
77801-4054
US

IV. Provider business mailing address

4305 COLLEGE MAIN ST APT 16
BRYAN TX
77801-4054
US

V. Phone/Fax

Practice location:
  • Phone: 304-417-1650
  • Fax:
Mailing address:
  • Phone: 304-417-1650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number344016
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: