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General NPI Number Information
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NPI Number | 1417034745
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Entity Type | Organization
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Legal Business Name | SOUTH LOOP 12 MEDICAL CLINIC LLC
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 10/09/2014
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Provider Practice Location Address
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Address Line | 3232 GREAT TRINITY FOREST WAY STE. 102
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City | DALLAS
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State | TX
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Zip | 75216-7732
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Country | US
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Telephone | 214-398-4157
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Fax | 214-398-4326
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Provider Business Mailing Address
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Address Line | 3232 GREAT TRINITY FOREST WAY STE. 102
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City | DALLAS
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State | TX
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Zip | 75216-7732
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Country | US
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Telephone | 214-398-4157
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Fax | 214-398-4326
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Authorized Official
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Title or Position | FAMILY NURSE PACTITIONE CERTIFIED
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Name | MS. CONNIE FRANCES NELLUM
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Credential | MS, APRN-C
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Telephone | 214-398-4157
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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 | 528675
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License Number State | TX
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