Provider Demographics
NPI:1821740796
Name:JOHN, ABIGAIL GRACE (APRN, FNP-BC, NP-C)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:GRACE
Last Name:JOHN
Suffix:
Gender:F
Credentials:APRN, FNP-BC, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 N CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5306
Mailing Address - Country:US
Mailing Address - Phone:817-329-6263
Mailing Address - Fax:
Practice Address - Street 1:1170 N CARROLL AVE
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5306
Practice Address - Country:US
Practice Address - Phone:817-329-6263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1056599363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily