Healthcare Provider Details

I. General information

NPI: 1861864860
Provider Name (Legal Business Name): THERESA CARLSON AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2015
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4708 ALLIANCE BLVD STE 600
PLANO TX
75093-5368
US

IV. Provider business mailing address

4708 ALLIANCE BLVD STE 600
PLANO TX
75093-5368
US

V. Phone/Fax

Practice location:
  • Phone: 469-467-0011
  • Fax: 469-467-4923
Mailing address:
  • Phone: 469-467-0011
  • Fax: 469-467-4923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP129474
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: