Provider Demographics
NPI:1417034745
Name:SOUTH LOOP 12 MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:SOUTH LOOP 12 MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PACTITIONE CERTIFIED
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:NELLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MS, APRN-C
Authorized Official - Phone:214-398-4157
Mailing Address - Street 1:3232 GREAT TRINITY FOREST WAY
Mailing Address - Street 2:STE. 102
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-7732
Mailing Address - Country:US
Mailing Address - Phone:214-398-4157
Mailing Address - Fax:214-398-4326
Practice Address - Street 1:3232 GREAT TRINITY FOREST WAY
Practice Address - Street 2:STE. 102
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7732
Practice Address - Country:US
Practice Address - Phone:214-398-4157
Practice Address - Fax:214-398-4326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX528675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018919303Medicaid
TX5608640OtherFIRST HEALTH PROVIDER ID
TX7438197OtherAETNA PROVIDER ID#
TX8N8001OtherBCBC PROVIDER ID#
TX16541Medicare UPIN
TX00474WMedicare ID - Type UnspecifiedPROVIDER ID
TX018919303Medicaid