Basic Information
Provider Information | |||||||||
NPI: | 1861675753 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ENRIQUEZ | ||||||||
FirstName: | SUSANA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN FNPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2500 E MAIN | ||||||||
Address2: |   | ||||||||
City: | ALICE | ||||||||
State: | TX | ||||||||
PostalCode: | 78332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3616618000 | ||||||||
FaxNumber: | 3616618073 | ||||||||
Practice Location | |||||||||
Address1: | 123 SOUTH MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | FREER | ||||||||
State: | TX | ||||||||
PostalCode: | 78357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3613947311 | ||||||||
FaxNumber: | 3613947158 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2007 | ||||||||
LastUpdateDate: | 12/13/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F0807232 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.