MEDICARE: MRS. ANGELA MARDINE GEORGE WHNP-BC

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	363LW0102X	Women's Health Nurse Practitioner	684632	TX

General Provider Information

NPI Number	:	1912217662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANGELA MARDINE GEORGE WHNP-BC

Provider Business Mailing Address
First Line	:	4312 HERITAGE TRACE PKWY
Second Line	:	SUITE 700
City	:	FORT WORTH
State	:	TX
Zip	:	76244-9132
Country	:	US
Telephone Number	:	817-741-9663
Fax Number	:	817-741-3691

Provider Business Practice Location Address
First Line	:	10600 N RIVERSIDE DR STE 100
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-9505
Country	:	US
Telephone Number	:	817-741-9663
Fax Number	:

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

Provider Enumeration Date	:	10/15/2010
Last Update Date	:	01/08/2025

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