Provider Demographics
NPI:1023867546
Name:ITASCA HEALING MEDICAL PRACTICE
Entity type:Organization
Organization Name:ITASCA HEALING MEDICAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNA
Authorized Official - Middle Name:ITASCA
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:936-250-2062
Mailing Address - Street 1:223 KING ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4421
Mailing Address - Country:US
Mailing Address - Phone:936-622-0552
Mailing Address - Fax:936-622-0554
Practice Address - Street 1:223 KING ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4421
Practice Address - Country:US
Practice Address - Phone:936-622-0552
Practice Address - Fax:936-622-0554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-16
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty