=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245731629
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYWANNA JEMISON II
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2018
-----------------------------------------------------
Last Update Date | 02/22/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3747 VARLA LN
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77014-2721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-576-0127
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3747 VARLA LN
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77014-2721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-576-0127
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 213996
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------