Healthcare Provider Details

I. General information

NPI: 1265163596
Provider Name (Legal Business Name): MARIA GILLESPIE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 06/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 STONE OAK LOOP
SAN ANTONIO TX
78258-3391
US

IV. Provider business mailing address

29 OUTER OCTAGON
UNIVERSAL CITY TX
78148-5602
US

V. Phone/Fax

Practice location:
  • Phone: 210-495-7334
  • Fax:
Mailing address:
  • Phone: 937-789-5709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1018068
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: