Provider Demographics
NPI:1336218908
Name:PHIFER, MARY ALICE (RN C FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALICE
Last Name:PHIFER
Suffix:
Gender:F
Credentials:RN C FNP
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ALICE
Other - Last Name:GRAMZOW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:4738 LITTLE ROAD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017
Mailing Address - Country:US
Mailing Address - Phone:817-483-8599
Mailing Address - Fax:817-483-2440
Practice Address - Street 1:4738 LITTLE ROAD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017
Practice Address - Country:US
Practice Address - Phone:817-483-8599
Practice Address - Fax:817-483-2440
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX435681363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S63446Medicare UPIN
TX8A8569Medicare ID - Type Unspecified