MEDICARE: ELISSA KALINCHUK GUADARRAMA RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	168502	TX
2	163WM0705X	Medical-Surgical Registered Nurse	915339	TX

General Provider Information

NPI Number	:	1245355056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISSA KALINCHUK GUADARRAMA RN

Provider Business Mailing Address
First Line	:	7938 NEW WORLD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78239-3515
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7938 NEW WORLD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78239-3515
Country	:	US
Telephone Number	:	830-719-3096
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	08/02/2022

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