Healthcare Provider Details

I. General information

NPI: 1295661817
Provider Name (Legal Business Name): MARISA VICTORIA PODOLAK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 WINONA DR
PLANO TX
75074-2726
US

IV. Provider business mailing address

2005 WINONA DR
PLANO TX
75074-2726
US

V. Phone/Fax

Practice location:
  • Phone: 214-471-1641
  • Fax:
Mailing address:
  • Phone: 214-471-1641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1235451
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: