MEDICARE: SOUR LAKE HEALTH & MEDICAL, PLLC

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	363LF0000X	Family Nurse Practitioner	712554	TX

General Provider Information

NPI Number	:	1346511433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUR LAKE HEALTH & MEDICAL, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 429
Second Line	:
City	:	SOUR LAKE
State	:	TX
Zip	:	77659-0429
Country	:	US
Telephone Number	:	409-287-4100
Fax Number	:	409-287-4105

Provider Business Practice Location Address
First Line	:	689 SIXTH STREET
Second Line	:
City	:	SOUR LAKE
State	:	TX
Zip	:	77659-1870
Country	:	US
Telephone Number	:	409-287-4100
Fax Number	:	409-287-4105

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. LACEY GUEDRY
Credential	:	MSN, APRN, FNP-C
Telephone Number	:	409-287-4100

Provider Enumeration Date	:	01/20/2012
Last Update Date	:	03/27/2019

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