MEDICARE: ERIN COLLEEN WILLBANKS PMHNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	730109	TX

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	8N0217	OTHER	TX	BLUE CROSS BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538436498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN COLLEEN WILLBANKS PMHNP

Provider Business Mailing Address
First Line	:	2400 NW 24TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76106-6629
Country	:	US
Telephone Number	:	817-569-5401
Fax Number	:	817-569-5042

Provider Business Practice Location Address
First Line	:	2400 NW 24TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76106-6629
Country	:	US
Telephone Number	:	817-569-5401
Fax Number	:	817-569-5042

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

Provider Enumeration Date	:	11/21/2011
Last Update Date	:	07/18/2014

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