Healthcare Provider Details

I. General information

NPI: 1508363805
Provider Name (Legal Business Name): ELODIE VIDEHOUN WEST NPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 ELIZABETH ST FL 3
CORPUS CHRISTI TX
78404-2212
US

IV. Provider business mailing address

718 ELIZABETH ST FL 3
CORPUS CHRISTI TX
78404-2212
US

V. Phone/Fax

Practice location:
  • Phone: 361-884-2858
  • Fax: 361-879-9015
Mailing address:
  • Phone: 361-884-2858
  • Fax: 361-879-9015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP137259
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: