Healthcare Provider Details

I. General information

NPI: 1104507391
Provider Name (Legal Business Name): JUDY ANN DAO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 07/31/2023
Certification Date: 07/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4927 LAKE RIDGE PKWY STE 148
GRAND PRAIRIE TX
75052-3000
US

IV. Provider business mailing address

4927 LAKE RIDGE PKWY STE 148
GRAND PRAIRIE TX
75052-3000
US

V. Phone/Fax

Practice location:
  • Phone: 972-217-4203
  • Fax:
Mailing address:
  • Phone: 972-217-4203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1130095
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: