Provider Demographics
NPI:1750306882
Name:SWANSON, STEPHANIE (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12000 HORSESHOE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4804
Mailing Address - Country:US
Mailing Address - Phone:716-622-2969
Mailing Address - Fax:
Practice Address - Street 1:1125 DAVIS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-488-1956
Practice Address - Fax:813-488-8675
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334028363LF0000X
TXAP135304363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02777402Medicaid