1114447026 NPI number — BRENDA MARIE FITZGERALD MT123835

Table of content: LAURA K LANYON FNP (NPI 1891377495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114447026 NPI number — BRENDA MARIE FITZGERALD MT123835

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
BRENDA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MT123835
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:
1114447026
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 S CENTRAL EXPY STE 43
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHARDSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75080-6314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-566-9894
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 S. CENTRAL EXPRESSWAY
Provider Second Line Business Practice Location Address:
#43
Provider Business Practice Location Address City Name:
RICHARDSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-566-9894
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/21/2017

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: 225700000X , with the licence number:  MT123835 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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