=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679060941
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REENA MATHEW FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2018
-----------------------------------------------------
Last Update Date | 04/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4100 W 15TH ST STE 110
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-5826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-408-9558
-----------------------------------------------------
Fax | 888-408-9558
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 251382
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75025-1382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-786-0140
-----------------------------------------------------
Fax | 972-786-0142
-----------------------------------------------------
=====================================================
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 | AP137078
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------