Provider Demographics
NPI:1831143627
Name:WILLOUGHBY, GLORIA E (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:E
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 PINE FOREST DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77384-5302
Mailing Address - Country:US
Mailing Address - Phone:281-709-2555
Mailing Address - Fax:281-440-9915
Practice Address - Street 1:150 PINE FOREST DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-5302
Practice Address - Country:US
Practice Address - Phone:281-709-2555
Practice Address - Fax:281-440-9915
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX651038363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152611302Medicaid
TX187619502Medicaid
TX187619501Medicaid
TX152611301Medicaid
TX8F2987Medicare PIN
TXP53993Medicare UPIN
TX187619502Medicaid