Healthcare Provider Details

I. General information

NPI: 1508153438
Provider Name (Legal Business Name): DEITRA FALGOUT LEBOUEF APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 11/09/2024
Certification Date: 11/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5924 W PARKER RD STE 100
PLANO TX
75093-6417
US

IV. Provider business mailing address

6309 N PRESIDENT GEORGE BUSH HWY APT 9202
GARLAND TX
75044-5542
US

V. Phone/Fax

Practice location:
  • Phone: 972-697-5954
  • Fax: 469-259-2854
Mailing address:
  • Phone: 972-697-5954
  • Fax: 469-259-2854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number664217
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberAP120783
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP120783
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: