Provider Demographics
NPI:1164855078
Name:LARGE, STEPHANIE (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LARGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2553
Mailing Address - Country:US
Mailing Address - Phone:817-735-5058
Mailing Address - Fax:
Practice Address - Street 1:855 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-735-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX836232363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8364NJOtherBCBS
TX325708103Medicaid
TX8025NDOtherBCBS
TX325708101Medicaid
TX325708101Medicaid
TX317126YS0QMedicare PIN