Basic Information
| Provider Information | |||||||||
| NPI: | 1306110366 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | RENEA | ||||||||
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| Credential: | AGNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9229 LBJ FWY | ||||||||
| Address2: | ATTN: POST ACUTE | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752433405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6822363656 | ||||||||
| FaxNumber: | 2145701692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 E LANCASTER AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761026671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177028391 | ||||||||
| FaxNumber: | 8177024102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2012 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP117208 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 601924 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | 601924 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LA2200X | AP117208 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 8445NJ | 01 | TX | BCBS | OTHER | 8920NK | 01 | TX | BCBS | OTHER | 340549001 | 05 | TX | MEDICAID | 340549003 | 05 | TX | MEDICAID |