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General NPI Number Information
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NPI Number | 1700284056
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Entity Type | Organization
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Legal Business Name | CLINIC AND WELLNESS CENTERS, PLLC
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Dates
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Enumeration Date | 12/18/2014
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Last Update Date | 12/18/2014
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Provider Practice Location Address
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Address Line | 2771 E BROAD ST STE 217-109
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City | MANSFIELD
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State | TX
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Zip | 76063-9156
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Country | US
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Telephone | 817-209-7736
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Fax |
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Provider Business Mailing Address
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Address Line | 2771 E BROAD ST STE 217-109
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City | MANSFIELD
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State | TX
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Zip | 76063-9156
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Country | US
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Telephone | 817-209-7736
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Fax |
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Authorized Official
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Title or Position | FAMILY NURSE PRACTITIONER
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Name | MS. LASHONDA TRAYLOR
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Credential | FNP-C
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Telephone | 817-209-7736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | F0814245
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License Number State | TX
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