=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992703789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE ALISON MUELLER D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2005
-----------------------------------------------------
Last Update Date | 10/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 MEDICAL PLAZA CT
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048-5684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-279-9333
-----------------------------------------------------
Fax | 817-573-6234
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 MEDICAL PLAZA CT
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048-5684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-279-9333
-----------------------------------------------------
Fax | 817-573-6234
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | L7060
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 5101014224
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------