1831143627 NPI number — GLORIA E WILLOUGHBY NURSE PRACTITIONER

Table of content: GLORIA E WILLOUGHBY NURSE PRACTITIONER (NPI 1831143627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831143627 NPI number — GLORIA E WILLOUGHBY NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLOUGHBY
Provider First Name:
GLORIA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
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:
1831143627
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 PINE FOREST DR
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
SHENANDOAH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77384-5302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-709-2555
Provider Business Mailing Address Fax Number:
281-440-9915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 PINE FOREST DR
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
SHENANDOAH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77384-5302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-709-2555
Provider Business Practice Location Address Fax Number:
281-440-9915
Provider Enumeration Date:
05/19/2006

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: 363LF0000X , with the licence number:  651038 , 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)

  • Identifier: 152611302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 187619502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 187619501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 152611301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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