MEDICARE: ITASCA HEALING MEDICAL PRACTICE

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1023867546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ITASCA HEALING MEDICAL PRACTICE

Provider Business Mailing Address
First Line	:	223 KING ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-4421
Country	:	US
Telephone Number	:	936-622-0552
Fax Number	:	936-622-0554

Provider Business Practice Location Address
First Line	:	223 KING ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-4421
Country	:	US
Telephone Number	:	936-622-0552
Fax Number	:	936-622-0554

Authorized Official
Title or Position	:	OWNER
Name	:	SUZANNA ITASCA FULLER
Credential	:	FNP-C
Telephone Number	:	936-250-2062

Provider Enumeration Date	:	05/16/2024
Last Update Date	:	10/02/2024

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Directions to “ITASCA HEALING MEDICAL PRACTICE ” Practice Location

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