Healthcare Provider Details

I. General information

NPI: 1174969893
Provider Name (Legal Business Name): RAISSA AMEH WHNP, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 S BROADWAY AVE STE. 2
TYLER TX
75701-1677
US

IV. Provider business mailing address

4055 HOGAN DR #1409
TYLER TX
75709-6930
US

V. Phone/Fax

Practice location:
  • Phone: 903-939-2273
  • Fax: 903-581-2137
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number2371
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: