MEDICARE: ISATU J WELLINGTON 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
1	363LF0000X	Family Nurse Practitioner	751706	TX
2	363LF0000X	Family Nurse Practitioner	AP123830	TX

General Provider Information

NPI Number	:	1407288905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ISATU J WELLINGTON FNP-C

Provider Business Mailing Address
First Line	:	222 LAS COLINAS BLVD W
Second Line	:	SUITE 2000
City	:	IRVING
State	:	TX
Zip	:	75039-5421
Country	:	US
Telephone Number	:	972-957-3000
Fax Number	:	972-957-3005

Provider Business Practice Location Address
First Line	:	1200 WOODHAVEN BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-2376
Country	:	US
Telephone Number	:	817-429-8300
Fax Number	:	817-429-6167

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

Provider Enumeration Date	:	08/07/2013
Last Update Date	:	05/10/2017

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