Healthcare Provider Details

I. General information

NPI: 1346743648
Provider Name (Legal Business Name): GINA ANN HURD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 S MAIN ST
FORT WORTH TX
76104-1224
US

IV. Provider business mailing address

219 S MAIN ST
FORT WORTH TX
76104-1224
US

V. Phone/Fax

Practice location:
  • Phone: 817-265-0900
  • Fax:
Mailing address:
  • Phone: 817-265-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number142671
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: