Provider Demographics
NPI:1417368168
Name:FAITH MEDICAL CLINIC, PLLC
Entity Type:Organization
Organization Name:FAITH MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:806-557-4138
Mailing Address - Street 1:PO BOX 1614
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-1614
Mailing Address - Country:US
Mailing Address - Phone:806-557-4138
Mailing Address - Fax:806-557-4165
Practice Address - Street 1:1619 4TH AVE
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-3824
Practice Address - Country:US
Practice Address - Phone:806-557-4138
Practice Address - Fax:806-557-4165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-15
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP118557363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty