Healthcare Provider Details

I. General information

NPI: 1225786932
Provider Name (Legal Business Name): ALISA D CUPP APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9509 N BEACH ST STE 102
FORT WORTH TX
76244-6399
US

IV. Provider business mailing address

7012 GREENSPOINT DR
ARLINGTON TX
76001-6780
US

V. Phone/Fax

Practice location:
  • Phone: 817-396-7271
  • Fax:
Mailing address:
  • Phone: 806-220-6141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1056561
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: