=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538167853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST TEXAS A&M UNIVERSITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4400 S WASHINGTON ST SUITE 107
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79110-2052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-355-5721
-----------------------------------------------------
Fax | 806-355-5775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4400 S WASHINGTON ST SUITE 107
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79110-2052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-355-5721
-----------------------------------------------------
Fax | 806-355-5775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC MANAGER
-----------------------------------------------------
Name | MRS. KENDALL E BUNCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-355-5721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------