MEDICARE: STONEWALL FELLOWSHIP CHURCH

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	363LP0222X	Critical Care Pediatric Nurse Practitioner

General Provider Information

NPI Number	:	1134088172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STONEWALL FELLOWSHIP CHURCH

Provider Business Mailing Address
First Line	:	1303 SOUTH UNIVERSITY DR
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961
Country	:	US
Telephone Number	:	936-219-4611
Fax Number	:

Provider Business Practice Location Address
First Line	:	1303 SOUTH UNIVERSITY DR
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961
Country	:	US
Telephone Number	:	936-219-4611
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DESMOND TOLBERT
Credential	:
Telephone Number	:	936-219-4611

Provider Enumeration Date	:	01/16/2026
Last Update Date	:	01/16/2026

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Directions to “STONEWALL FELLOWSHIP CHURCH ” Practice Location

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