Healthcare Provider Details

I. General information

NPI: 1558840538
Provider Name (Legal Business Name): MINDY LEE HEGBLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W ROSEDALE ST
FT WORTH TX
76104-4672
US

IV. Provider business mailing address

7227 LEE DEFOREST DR
COLUMBIA MD
21046-3236
US

V. Phone/Fax

Practice location:
  • Phone: 260-482-7447
  • Fax:
Mailing address:
  • Phone: 410-910-3529
  • Fax: 410-910-1685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number888948
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: