Healthcare Provider Details

I. General information

NPI: 1316443484
Provider Name (Legal Business Name): LESA G ANSELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 W BELT LINE RD STE A
CEDAR HILL TX
75104-1105
US

IV. Provider business mailing address

6080 S HULEN ST STE 360 PMB 232
FORT WORTH TX
76132-4810
US

V. Phone/Fax

Practice location:
  • Phone: 972-291-1992
  • Fax: 972-637-7745
Mailing address:
  • Phone: 214-732-8805
  • Fax: 817-977-8981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP131295
License Number StateTX

VIII. Authorized Official

Name: LESA ANSELL
Title or Position: OWNER
Credential: APRN, AGNP-C, DC
Phone: 972-291-1992