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NPI Code Detail

MEDICARE: MYSTII ELLEN KIDD PNP

MEDICARE: MYSTII ELLEN KIDD PNP
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
1363LP2300XPrimary Care Nurse PractitionerAP107293TX

General Provider Information

NPI Number : 1437439221
Entity Type Code : Individual
Provider Name (Legal Business Name) : MYSTII ELLEN KIDD PNP
Provider Business Mailing Address
First Line : PO BOX 733784
Second Line :
City : DALLAS
State : TX
Zip : 75373-3784
Country : US
Telephone Number : 682-885-6483
Fax Number : 682-885-3113
Provider Business Practice Location Address
First Line : 4001 W 15TH ST STE 350
Second Line :
City : PLANO
State : TX
Zip : 75093-5863
Country : US
Telephone Number : 972-596-2131
Fax Number : 682-303-2031
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/24/2011
Last Update Date : 07/25/2022

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