Provider Demographics
NPI:1992338354
Name:GUDGER, AUDREY JANE (LVN)
Entity type:Individual
Prefix:MISS
First Name:AUDREY
Middle Name:JANE
Last Name:GUDGER
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13516 COUNTY ROAD 4200
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771-7904
Mailing Address - Country:US
Mailing Address - Phone:307-253-8260
Mailing Address - Fax:
Practice Address - Street 1:100 E FERGUSON ST STE 608
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5756
Practice Address - Country:US
Practice Address - Phone:903-705-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX329770164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse