MEDICARE: JENNIFER TATA 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	126382	TX
2	363LF0000X	Family Nurse Practitioner	AP126382	TX

General Provider Information

NPI Number	:	1548662976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER TATA FNP-C

Provider Business Mailing Address
First Line	:	122 W JOHN CARPENTER FWY STE 420
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75039-2014
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10058A LONG POINT RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77055-4002
Country	:	US
Telephone Number	:	832-380-3980
Fax Number	:

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

Provider Enumeration Date	:	09/17/2014
Last Update Date	:	03/17/2018

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