MEDICARE: MRS. GRACE UDO

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	164W00000X	Licensed Practical Nurse	LPN961787	DC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	27-3767580	OTHER		TAX ID#27-3767580

General Provider Information

NPI Number	:	1588931653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GRACE UDO

Provider Business Mailing Address
First Line	:	13927 WESTVIEW FOREST DR
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20720-4866
Country	:	US
Telephone Number	:	301-789-1006
Fax Number	:

Provider Business Practice Location Address
First Line	:	13927 WESTVIEW FOREST DR
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20720-4866
Country	:	US
Telephone Number	:	301-789-1006
Fax Number	:

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

Provider Enumeration Date	:	11/17/2011
Last Update Date	:	11/17/2011

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Directions to “ MRS. GRACE UDO ” Practice Location

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