=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164123014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CARE OF HENDERSON, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2023
-----------------------------------------------------
Last Update Date | 08/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 321 WILSON ST
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75652-5957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-392-0005
-----------------------------------------------------
Fax | 903-392-7772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 321 WILSON ST
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75652-5957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-392-0005
-----------------------------------------------------
Fax | 903-392-7772
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NP
-----------------------------------------------------
Name | MRS. BRENDA SUE IFFLAND
-----------------------------------------------------
Credential | APRN, FNP-C
-----------------------------------------------------
Telephone | 903-392-0005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------