Healthcare Provider Details

I. General information

NPI: 1306823703
Provider Name (Legal Business Name): ELAINE NICOLE SEXTON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 FT. RICHARDSON AVE 17 MEDICAL GROUP
GOODFELLOW AFB TX
76908
US

IV. Provider business mailing address

271 FT. RICHARDSON AVE 17 MEDICAL GROUP
GOODFELLOW AFB TX
76908
US

V. Phone/Fax

Practice location:
  • Phone: 325-654-3117
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN41041
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001216785
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: