Provider Demographics
NPI:1588270441
Name:WEBB, UNDRE (LPN)
Entity type:Individual
Prefix:
First Name:UNDRE
Middle Name:
Last Name:WEBB
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5654
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85010-5654
Mailing Address - Country:US
Mailing Address - Phone:480-524-1798
Mailing Address - Fax:
Practice Address - Street 1:567 W 11TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132-9126
Practice Address - Country:US
Practice Address - Phone:480-524-1798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP053491164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse