Healthcare Provider Details

I. General information

NPI: 1699332692
Provider Name (Legal Business Name): YOLANDA ROSHELL BATES AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: YOLANDA ROSHELL BULLOCK

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5304 E 5TH ST STE 113
KATY TX
77493-2532
US

IV. Provider business mailing address

5304 E 5TH ST STE 113
KATY TX
77493-2532
US

V. Phone/Fax

Practice location:
  • Phone: 346-307-7500
  • Fax: 346-307-7570
Mailing address:
  • Phone: 346-307-7500
  • Fax: 866-850-7784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number30275
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: