Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 6849 | TX |
NPI | 1407062979 |
---|---|
Provider Name | Edna Craven |
First Address | Irving, TX 75062-4453 |
Second Address | Irving, TX 75062-4453 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2007 |
Last Update Date | 08/07/2007 |