MEDICARE: LINDA PREBBLE RN, FNP

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	363L00000X	Nurse Practitioner	655175	TX
2	363LF0000X	Family Nurse Practitioner	2010012214	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	431560263	OTHER		TRICARE WEST

General Provider Information

NPI Number	:	1023053907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINDA PREBBLE RN, FNP

Provider Business Mailing Address
First Line	:	PO BOX 250
Second Line	:
City	:	MAMMOTH SPRING
State	:	AR
Zip	:	72554-0250
Country	:	US
Telephone Number	:	870-625-3228
Fax Number	:	870-625-3227

Provider Business Practice Location Address
First Line	:	260 SOUTH MAIN STREET
Second Line	:
City	:	MAMMOTH SPRING
State	:	AR
Zip	:	72554
Country	:	US
Telephone Number	:	807-625-3228
Fax Number	:	870-625-3227

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

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	08/06/2012

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