Healthcare Provider Details

I. General information

NPI: 1750071908
Provider Name (Legal Business Name): NISHA MARY GEORGE RN, APRN, AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NISHA MARY POULOSE

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981 STATE HIGHWAY 121 STE 1140
ALLEN TX
75013-6148
US

IV. Provider business mailing address

PO BOX 35629
DALLAS TX
75235-0629
US

V. Phone/Fax

Practice location:
  • Phone: 469-697-5100
  • Fax: 469-697-5105
Mailing address:
  • Phone: 214-424-2200
  • Fax: 214-231-2159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1098461
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: