Healthcare Provider Details

I. General information

NPI: 1003206152
Provider Name (Legal Business Name): MARISA GLADEN RN BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 MATLOCK RD STE 207
ARLINGTON TX
76015-2917
US

IV. Provider business mailing address

2717 SHADOW WOOD DR
ARLINGTON TX
76006-2727
US

V. Phone/Fax

Practice location:
  • Phone: 903-647-4512
  • Fax:
Mailing address:
  • Phone: 903-647-4512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number697482
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: