=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083263131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRISCILLA SHARON PICHON MPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2019
-----------------------------------------------------
Last Update Date | 08/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5750 W VICKERY BLVD STE 104
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76107-7448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-732-2878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19769 FM 2767
-----------------------------------------------------
City | WINONA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75792-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-372-3331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA14033
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------