MEDICARE: PAULA RENEE LANDRY

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1801502844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULA RENEE LANDRY

Provider Business Mailing Address
First Line	:	9112 NIGHTINGALE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2712
Country	:	US
Telephone Number	:	682-391-8320
Fax Number	:

Provider Business Practice Location Address
First Line	:	9112 NIGHTINGALE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2712
Country	:	US
Telephone Number	:	682-391-8320
Fax Number	:

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

Provider Enumeration Date	:	01/24/2023
Last Update Date	:	01/24/2023

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Directions to “ PAULA RENEE LANDRY ” Practice Location

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