Provider Demographics
NPI:1407510399
Name:MAIN, ELIZABETH BROOKE (FNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BROOKE
Last Name:MAIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4279 OLD HIGHWAY 135 S
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-7879
Mailing Address - Country:US
Mailing Address - Phone:903-374-5465
Mailing Address - Fax:
Practice Address - Street 1:804 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HALLSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75650-5102
Practice Address - Country:US
Practice Address - Phone:903-374-5465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF09210916363LP2300X
TX1059117363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care