Healthcare Provider Details

I. General information

NPI: 1841069309
Provider Name (Legal Business Name): 180 HEALTH CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2023
Last Update Date: 12/26/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 EASTCHASE PKWY STE 123
FORT WORTH TX
76120-4425
US

IV. Provider business mailing address

PO BOX 200172
ARLINGTON TX
76006-0172
US

V. Phone/Fax

Practice location:
  • Phone: 682-622-8990
  • Fax:
Mailing address:
  • Phone: 919-623-0408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. APRIL LA SHONDA PHILLIPS
Title or Position: OWNER/NP
Credential: APRN-C, AGPCNP-C
Phone: 919-623-0408