Provider Demographics
NPI:1326098625
Name:HIATT, MARY L (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:HIATT
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4611
Mailing Address - Country:US
Mailing Address - Phone:817-759-7000
Mailing Address - Fax:817-759-7027
Practice Address - Street 1:920 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5864
Practice Address - Country:US
Practice Address - Phone:817-759-7000
Practice Address - Fax:817-759-7027
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP112335363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1565509-05Medicaid
TX1565509-05Medicaid
TXNP0430Medicare PIN
TX243291Medicare UPIN