Provider Demographics
NPI:1184660086
Name:PURCELL, JANNINE
Entity Type:Individual
Prefix:
First Name:JANNINE
Middle Name:
Last Name:PURCELL
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST STE 550
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8366
Practice Address - Country:US
Practice Address - Phone:903-510-8718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0327363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977--008OtherTRICARE
TXP01635758OtherRAIL ROAD MEDICARE
TX359051501Medicaid
TX8979NUOtherBCBS
S40101Medicare PIN
TXP01635758OtherRAIL ROAD MEDICARE