Provider Demographics
NPI:1245214808
Name:POGUE, STEVELYNN J (GNP)
Entity Type:Individual
Prefix:
First Name:STEVELYNN
Middle Name:J
Last Name:POGUE
Suffix:
Gender:F
Credentials:GNP
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 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9202 ELAM RD
Practice Address - Street 2:SOUTHEAST DALLAS HEALTH CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-4151
Practice Address - Country:US
Practice Address - Phone:214-266-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX416332363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y0754OtherBLUE CROSS BLUE SHIELD
TX138907408Medicaid
TX138907407Medicaid
TX138907410Medicaid
TX138907411Medicaid
TX138907412Medicaid
TX500029400OtherRAILROAD MEDICARE
TX138907403Medicaid
TX138907401Medicaid
TX138907402Medicaid
TX138907404Medicaid
TX138907405Medicaid
TX138907406Medicaid
TX86N655Medicare ID - Type Unspecified
TX138907401Medicaid