Provider Demographics
NPI:1477262772
Name:ITA, GEORGINA
Entity Type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:ITA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10701 CORPORATE DR STE 340-105
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-4096
Mailing Address - Country:US
Mailing Address - Phone:281-903-0171
Mailing Address - Fax:
Practice Address - Street 1:10701 CORPORATE DR STE 340-105
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-4096
Practice Address - Country:US
Practice Address - Phone:281-903-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1097436363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty