Provider Demographics
NPI:1215536586
Name:THEISS, MARY AMANDA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:AMANDA
Last Name:THEISS
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 1:8434 RAINTREE WOODS DR
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS RANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78015-4437
Mailing Address - Country:US
Mailing Address - Phone:318-376-3819
Mailing Address - Fax:
Practice Address - Street 1:8434 RAINTREE WOODS DR
Practice Address - Street 2:
Practice Address - City:FAIR OAKS RANCH
Practice Address - State:TX
Practice Address - Zip Code:78015-4437
Practice Address - Country:US
Practice Address - Phone:318-376-3819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX879598163W00000X
TX1030889367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse