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NPI Code Detail

MEDICARE: CAROLYN RENE PETRENCIK FNP-C

MEDICARE: CAROLYN RENE PETRENCIK FNP-C
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
1363LF0000XFamily Nurse Practitioner1070718TX
2208100000XPhysical Medicine & Rehabilitation Physician1070718TX

General Provider Information

NPI Number : 1194470757
Entity Type Code : Individual
Provider Name (Legal Business Name) : CAROLYN RENE PETRENCIK FNP-C
Provider Business Mailing Address
First Line : 3408 VISTA LAKE CIR
Second Line :
City : MANSFIELD
State : TX
Zip : 76063-5834
Country : US
Telephone Number : 817-919-9434
Fax Number :
Provider Business Practice Location Address
First Line : 716 N HIGHWAY 67 STE 2
Second Line :
City : CEDAR HILL
State : TX
Zip : 75104-2117
Country : US
Telephone Number : 972-291-9165
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/12/2022
Last Update Date : 10/10/2024

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