Healthcare Provider Details

I. General information

NPI: 1598964173
Provider Name (Legal Business Name): TOMMIE VIDALES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 JOHN DUPREE DR
LEVELLAND TX
79336-6326
US

IV. Provider business mailing address

1804 COLLEGE AVE
LEVELLAND TX
79336-6507
US

V. Phone/Fax

Practice location:
  • Phone: 806-894-2465
  • Fax: 806-894-8897
Mailing address:
  • Phone: 806-894-3141
  • Fax: 806-894-7094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number642208
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: