=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649858705
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL PETRIE APRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2021
-----------------------------------------------------
Last Update Date | 07/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2403 S STEMMONS FWY STE 105
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75067-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-829-6206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2403 S STEMMONS FWY STE 105
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75067-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-829-6206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1030522
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------