Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 4769 | TX |
NPI | 1083749790 |
---|---|
Provider Name | Juanee Surprise |
First Address | Oak Point, TX 75068-2236 |
Second Address | Denton, TX 76205-5121 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2007 |
Last Update Date | 08/07/2007 |