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General NPI Number Information
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NPI Number | 1417368168
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Entity Type | Organization
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Legal Business Name | FAITH MEDICAL CLINIC, PLLC
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Dates
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Enumeration Date | 05/15/2014
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Last Update Date | 03/02/2022
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Provider Practice Location Address
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Address Line | 1619 4TH AVE
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City | CANYON
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State | TX
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Zip | 79015-3824
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Country | US
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Telephone | 806-557-4138
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Fax | 806-557-4165
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Provider Business Mailing Address
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Address Line | PO BOX 1614
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City | CANYON
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State | TX
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Zip | 79015-1614
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Country | US
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Telephone | 806-557-4138
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Fax | 806-557-4165
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Authorized Official
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Title or Position | OWNER
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Name | MRS. GLORIA R FULLER
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Credential | FNP
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Telephone | 806-557-4138
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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 | AP118557
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License Number State | TX
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