Provider Demographics
NPI:1316483092
Name:BUNDICK, LYDIA (RN)
Entity type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:
Last Name:BUNDICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 CALDER ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1845
Mailing Address - Country:US
Mailing Address - Phone:409-833-9797
Mailing Address - Fax:409-654-6886
Practice Address - Street 1:2929 CALDER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1845
Practice Address - Country:US
Practice Address - Phone:409-833-9797
Practice Address - Fax:409-654-6921
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX804089163W00000X
TXAP133119363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX368262701Medicaid