MEDICARE: MARY SAMANTHA PAILES NP

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	363LA2200X	Adult Health Nurse Practitioner	709408	TX
2	363LF0000X	Family Nurse Practitioner	709408	TX

General Provider Information

NPI Number	:	1528498433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY SAMANTHA PAILES NP

Provider Business Mailing Address
First Line	:	620 N KIMBALL AVE SUITE 100
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-6173
Country	:	US
Telephone Number	:	817-328-8376
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 NORTH KIMBALL AVENUE
Second Line	:	SUITE100
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-6173
Country	:	US
Telephone Number	:	817-328-8376
Fax Number	:

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

Provider Enumeration Date	:	11/14/2013
Last Update Date	:	08/29/2023

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