MEDICARE: IMMANUEL FAMILY CLINIC PLLC

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	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1265072490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMMANUEL FAMILY CLINIC PLLC

Provider Business Mailing Address
First Line	:	2760 E TRINITY MILLS RD STE 115
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75006-2194
Country	:	US
Telephone Number	:	469-900-8211
Fax Number	:	214-617-0478

Provider Business Practice Location Address
First Line	:	2760 E TRINITY MILLS RD STE 115
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75006-2194
Country	:	US
Telephone Number	:	469-900-8211
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SUTHA M FERNANDO
Credential	:	FNP
Telephone Number	:	214-625-2808

Provider Enumeration Date	:	01/15/2020
Last Update Date	:	02/11/2020

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