=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356060909
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER SOLLOCK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2022
-----------------------------------------------------
Last Update Date | 08/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2605 W HOLCOMBE BLVD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-778-8106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 BAY AREA BLVD APT 12112
-----------------------------------------------------
City | LA PORTE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77571-5095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 |
-----------------------------------------------------