Provider Demographics
NPI:1821750175
Name:WHITEHEAD, EMMA BOLES (FNP)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:BOLES
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 TENAHA ST
Mailing Address - Street 2:
Mailing Address - City:CENTER
Mailing Address - State:TX
Mailing Address - Zip Code:75935-3404
Mailing Address - Country:US
Mailing Address - Phone:936-598-2716
Mailing Address - Fax:
Practice Address - Street 1:620 TENAHA ST
Practice Address - Street 2:
Practice Address - City:CENTER
Practice Address - State:TX
Practice Address - Zip Code:75935-3404
Practice Address - Country:US
Practice Address - Phone:936-598-2671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1056609363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1821750175Medicaid