Provider Demographics
NPI:1568883858
Name:CARMEN PEMBERTON PLLC
Entity Type:Organization
Organization Name:CARMEN PEMBERTON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:LOREN
Authorized Official - Last Name:PEMBERTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, FPMHNP
Authorized Official - Phone:817-416-7500
Mailing Address - Street 1:1135 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7533
Mailing Address - Country:US
Mailing Address - Phone:817-416-7500
Mailing Address - Fax:817-416-7565
Practice Address - Street 1:1135 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7533
Practice Address - Country:US
Practice Address - Phone:817-416-7500
Practice Address - Fax:817-416-7565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX590614261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health