=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043944952
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED NPS OF NORTH TEXAS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2022
-----------------------------------------------------
Last Update Date | 01/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 MEDICAL PKWY
-----------------------------------------------------
City | FARMERS BRANCH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75234-7829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-563-4146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14902 PRESTON RD STE 404-813
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75254-9105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-563-4146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | KAITLIN BLALOCK
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 903-563-4146
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------