Provider Demographics
NPI:1346676103
Name:RUST, ADRIENNE (CPNP)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:RUST
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:
Other - Last Name:BLAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 JEROME ST STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3939
Mailing Address - Country:US
Mailing Address - Phone:817-922-0800
Mailing Address - Fax:817-922-0805
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-1475
Practice Address - Fax:682-885-7520
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP124540363LP0200X
TX750214363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1346676103Medicaid