Provider Demographics
NPI:1013551233
Name:UPCHURCH, DALLAS LEIGH
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:LEIGH
Last Name:UPCHURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 KENDRA DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-5878
Mailing Address - Country:US
Mailing Address - Phone:706-326-6088
Mailing Address - Fax:
Practice Address - Street 1:345 OWEN LN STE 144A
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5587
Practice Address - Country:US
Practice Address - Phone:254-300-4072
Practice Address - Fax:254-362-2064
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1073418363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty