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General NPI Number Information
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NPI Number | 1265072490
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Entity Type | Organization
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Legal Business Name | IMMANUEL FAMILY CLINIC PLLC
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Dates
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Enumeration Date | 01/15/2020
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Last Update Date | 02/11/2020
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Provider Practice Location Address
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Address Line | 2760 E TRINITY MILLS RD STE 115
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City | CARROLLTON
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State | TX
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Zip | 75006-2194
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Country | US
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Telephone | 469-900-8211
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Fax |
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Provider Business Mailing Address
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Address Line | 2760 E TRINITY MILLS RD STE 115
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City | CARROLLTON
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State | TX
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Zip | 75006-2194
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Country | US
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Telephone | 469-900-8211
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Fax | 214-617-0478
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Authorized Official
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Title or Position | OWNER
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Name | SUTHA M FERNANDO
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Credential | FNP
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Telephone | 214-625-2808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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