{
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"EIN": null,
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"OtherCredential": "WIG EXPERT COSMOTOL",
"OtherLastNameTypeCode": "2",
"FirstLineMailingAddress": "9555 LEBANON RD",
"SecondLineMailingAddress": "102",
"MailingAddressCityName": "FRISCO",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "75035-6095",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "903-821-1875",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "104 BROADWAY ST",
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"PracticeLocationAddressCityName": "WHITESBORO",
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"PracticeLocationAddressCountryCode": "US",
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"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "12/01/2007",
"LastUpdateDate": "12/01/2007",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Prosthetic/Orthotic Supplier",
"LicenseNumber": "887136",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}