Provider Demographics
NPI:1922587872
Name:PROVENCE, ABI MIKKEL (MSN, FNP-BC & FNP-C)
Entity Type:Individual
Prefix:
First Name:ABI
Middle Name:MIKKEL
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:MSN, FNP-BC & FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 170428
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76003-0428
Mailing Address - Country:US
Mailing Address - Phone:817-729-7853
Mailing Address - Fax:
Practice Address - Street 1:6108 SHOREWOOD DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76016-2649
Practice Address - Country:US
Practice Address - Phone:817-435-2812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138443363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care