Provider Demographics
NPI:1013417591
Name:PRIMM, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:PRIMM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 1ST ST NE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:TX
Mailing Address - Zip Code:75436-1969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 1ST ST NE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:TX
Practice Address - Zip Code:75436-1969
Practice Address - Country:US
Practice Address - Phone:903-249-1206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX196006164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse