MEDICARE: MRS. ANTRESA JOYCE WEATHERSBY FNP-BC

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	699559	TX

General Provider Information

NPI Number	:	1750683264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANTRESA JOYCE WEATHERSBY FNP-BC

Provider Business Mailing Address
First Line	:	5711 SUMATRA DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-1808
Country	:	US
Telephone Number	:	214-718-6550
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 HIGHWAY 287 N STE 300
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-2632
Country	:	US
Telephone Number	:	817-539-0770
Fax Number	:

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

Provider Enumeration Date	:	12/03/2010
Last Update Date	:	12/03/2010

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