=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215954755
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE FAWN DUPRE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 04/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5950 SARATOGA BLVD
-----------------------------------------------------
City | CORPUS CHRISTI
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78414-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-985-5811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14493 SPID DR STE A #380
-----------------------------------------------------
City | CORPUS CHRISTI
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78418-5939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-445-9306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 34812
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 22275
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | M1663
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------