=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841069309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 180 HEALTH CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2023
-----------------------------------------------------
Last Update Date | 12/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 EASTCHASE PKWY STE 123
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76120-4425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-622-8990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 200172
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76006-0172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-623-0408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/NP
-----------------------------------------------------
Name | MS. APRIL LA SHONDA PHILLIPS
-----------------------------------------------------
Credential | APRN-C, AGPCNP-C
-----------------------------------------------------
Telephone | 919-623-0408
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------