MEDICARE: COURTNEY PRIMM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	196006	TX

General Provider Information

NPI Number	:	1013417591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY PRIMM

Provider Business Mailing Address
First Line	:	145 1ST ST NE
Second Line	:
City	:	DETROIT
State	:	TX
Zip	:	75436-1969
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 1ST ST NE
Second Line	:
City	:	DETROIT
State	:	TX
Zip	:	75436-1969
Country	:	US
Telephone Number	:	903-249-1206
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2018
Last Update Date	:	02/20/2018

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Directions to “ COURTNEY PRIMM ” Practice Location

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