Healthcare Provider Details

I. General information

NPI: 1164101242
Provider Name (Legal Business Name): STEPHANIE NICHOLE CHESTNUT AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 WALLACE BLVD
AMARILLO TX
79106-1799
US

IV. Provider business mailing address

6 MEDICAL DR
AMARILLO TX
79106-4136
US

V. Phone/Fax

Practice location:
  • Phone: 806-212-2000
  • Fax:
Mailing address:
  • Phone: 806-212-6604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1128712
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: