MEDICARE: BETH ANN TACKETT-MIRABAL RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WX1100X	Ophthalmic Registered Nurse	723934	TX

General Provider Information

NPI Number	:	1023862232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH ANN TACKETT-MIRABAL RN

Provider Business Mailing Address
First Line	:	1025 LONG PRAIRIE RD STE 100
Second Line	:
City	:	FLOWER MOUND
State	:	TX
Zip	:	75022-4346
Country	:	US
Telephone Number	:	972-874-2407
Fax Number	:	972-874-2733

Provider Business Practice Location Address
First Line	:	1025 LONG PRAIRIE RD STE 100
Second Line	:
City	:	FLOWER MOUND
State	:	TX
Zip	:	75022-4346
Country	:	US
Telephone Number	:	972-874-2407
Fax Number	:	972-874-2733

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2024
Last Update Date	:	04/15/2024

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