Healthcare Provider Details

I. General information

NPI: 1821750175
Provider Name (Legal Business Name): EMMA BOLES WHITEHEAD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 TENAHA ST
CENTER TX
75935-3404
US

IV. Provider business mailing address

620 TENAHA ST
CENTER TX
75935-3404
US

V. Phone/Fax

Practice location:
  • Phone: 936-598-2671
  • Fax:
Mailing address:
  • Phone: 936-598-2716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1056609
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: