Provider Demographics
NPI:1790224608
Name:BUSH, EMILY (LVN)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 MUSTANG DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-5640
Mailing Address - Country:US
Mailing Address - Phone:214-635-9550
Mailing Address - Fax:
Practice Address - Street 1:4625 MUSTANG DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-5640
Practice Address - Country:US
Practice Address - Phone:214-635-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX336442164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse