Healthcare Provider Details

I. General information

NPI: 1952394512
Provider Name (Legal Business Name): SALLY S MCMILLAN-DENGERUD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 S LOOP 256 SUITE 100
PALESTINE TX
75801-6958
US

IV. Provider business mailing address

PO BOX 817
PALESTINE TX
75802-0817
US

V. Phone/Fax

Practice location:
  • Phone: 903-723-8210
  • Fax: 903-723-8310
Mailing address:
  • Phone: 903-727-0110
  • Fax: 903-727-0210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number219839
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: