Provider Demographics
NPI:1811179815
Name:TEXAS, MARY LORENE (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LORENE
Last Name:TEXAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6903 BARBROOK RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-2773
Mailing Address - Country:US
Mailing Address - Phone:502-935-4163
Mailing Address - Fax:
Practice Address - Street 1:4309 BISHOP LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-4517
Practice Address - Country:US
Practice Address - Phone:502-485-3387
Practice Address - Fax:502-485-3670
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002542B363LF0000X
KY3006053363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000944673 (KOHMG)OtherANTHEM
KY000000944673 (KOHMG)OtherANTHEM
KYP01522516 RR (KOHMG)Medicare PIN