Basic Information
| Provider Information | |||||||||
| NPI: | 1639337546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZIMMERMANN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | ACNS-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1319 SUMMIT AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761024432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173360551 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1319 SUMMIT AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761024432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173360551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2008 | ||||||||
| LastUpdateDate: | 09/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2200X | 662977 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 2006003835-05 | 01 | TX | ANCC | OTHER |