Healthcare Provider Details

I. General information

NPI: 1043987738
Provider Name (Legal Business Name): LORI ELIZABETH SECEROVIC NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SOUTH INTERSTATE 35 EAST
DESOTO TX
75115
US

IV. Provider business mailing address

3412 DWYER LN
FLOWER MOUND TX
75022-2869
US

V. Phone/Fax

Practice location:
  • Phone: 469-341-7800
  • Fax:
Mailing address:
  • Phone: 239-691-4027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021040600
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: