Provider Demographics
NPI:1306825120
Name:SAMPLE, JANICE A (RN, FNP)
Entity Type:Individual
Prefix:MS
First Name:JANICE
Middle Name:A
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:5002 COWHORN CREEK RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-9766
Practice Address - Country:US
Practice Address - Phone:903-614-3000
Practice Address - Fax:903-614-3525
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01558363L00000X
TXA01558363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155665758Medicaid
TX8N7205OtherBLUE CROSS BLUE SHIELD
TX8D0528Medicare ID - Type Unspecified
TXDB9903Medicare ID - Type UnspecifiedRAILROAD
AR155665758Medicaid
TXP11436Medicare UPIN