=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669918603
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN BERTRAND KING NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2017
-----------------------------------------------------
Last Update Date | 11/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6720 BERTNER AVE
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77030-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-355-3484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10020 RESEARCH FOREST DR UNIT D
-----------------------------------------------------
City | THE WOODLANDS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77354-6780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 827-896-0013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 550551
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | AP130256
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | AP130256
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------