=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891488177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATELYN MANUEL APRN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2023
-----------------------------------------------------
Last Update Date | 06/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1651 W ROSEDALE ST STE 200
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-7437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-335-4316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 LAKE VIS E
-----------------------------------------------------
City | HIGHLAND VILLAGE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75077-6811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-675-5541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 1119118
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------