1063799856 NPI number — MS. GRACIE MAE ADKISSON PMHNP-BC

Table of content: MS. GRACIE MAE ADKISSON PMHNP-BC (NPI 1063799856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063799856 NPI number — MS. GRACIE MAE ADKISSON PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADKISSON
Provider First Name:
GRACIE
Provider Middle Name:
MAE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063799856
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5812 MCKNIGHT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75503-0960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-278-5906
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 PECAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71854-3656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-278-5906
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  AP126190 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 0024177015 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: AP4254 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AP126190 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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