=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790264943
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELENA CARLOCK RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2018
-----------------------------------------------------
Last Update Date | 08/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 602 W SEMANDS ST
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77301-1867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-249-2244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25503 THISTLEWAITE LN
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77373-3165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-490-3133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Registered Nurse
-----------------------------------------------------
License Number | 235221
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------