Healthcare Provider Details

I. General information

NPI: 1689624512
Provider Name (Legal Business Name): GINA MARIA BLOUNT RN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W MAIN ST
VAN TX
75790-2883
US

IV. Provider business mailing address

113 W MAIN ST
VAN TX
75790-2883
US

V. Phone/Fax

Practice location:
  • Phone: 903-963-8303
  • Fax: 903-963-5863
Mailing address:
  • Phone: 903-963-8303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number513569
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: