MEDICARE: MS. MABLE CLAIRE MCCALL FNP

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	163WC1500X	Community Health Registered Nurse	5700063	TX
2	163WP2201X	Ambulatory Care Registered Nurse	5700063	TX
3	163WW0101X	Ambulatory Women's Health Care Registered Nurse	5700063	TX

General Provider Information

NPI Number	:	1619212891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MABLE CLAIRE MCCALL FNP

Provider Business Mailing Address
First Line	:	4105 JUNIUS STREET
Second Line	:	AGAPE CLINIC
City	:	DALLAS
State	:	TX
Zip	:	75246
Country	:	US
Telephone Number	:	214-824-2744
Fax Number	:	214-823-9952

Provider Business Practice Location Address
First Line	:	4105 JUNIUS STREET
Second Line	:	AGAPE CLINIC @ GUMC
City	:	DALLAS
State	:	TX
Zip	:	75246
Country	:	US
Telephone Number	:	214-824-2744
Fax Number	:	214-823-9952

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

Provider Enumeration Date	:	11/29/2012
Last Update Date	:	11/29/2012

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