MEDICARE: MRS. MARITA JOAN PRINCE DNP

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	163W00000X	Registered Nurse	RN132098	AZ
2	390200000X	Student in an Organized Health Care Education/Training Program	RN132098	AZ
3	363LF0000X	Family Nurse Practitioner	241332	AZ

General Provider Information

NPI Number	:	1649252438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARITA JOAN PRINCE DNP

Provider Business Mailing Address
First Line	:	4313 FAIRWAY PATH
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78665-1455
Country	:	US
Telephone Number	:	573-855-2576
Fax Number	:

Provider Business Practice Location Address
First Line	:	36065 SANTA FE AVE
Second Line	:
City	:	FORT HOOD
State	:	TX
Zip	:	76544-5060
Country	:	US
Telephone Number	:	301-295-9004
Fax Number	:

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

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	07/21/2022

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