Provider Demographics
NPI:1588931653
Name:UDO, GRACE
Entity type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:
Last Name:UDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13927 WESTVIEW FOREST DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4866
Mailing Address - Country:US
Mailing Address - Phone:301-789-1006
Mailing Address - Fax:
Practice Address - Street 1:13927 WESTVIEW FOREST DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4866
Practice Address - Country:US
Practice Address - Phone:301-789-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN961787164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
27-3767580OtherTAX ID#27-3767580