Provider Demographics
NPI:1831442490
Name:PLOURDE, SALLY B (PNP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:B
Last Name:PLOURDE
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9411 N LAMAR BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-4179
Mailing Address - Country:US
Mailing Address - Phone:512-583-9679
Mailing Address - Fax:512-233-0985
Practice Address - Street 1:6425 S IH 35 STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-4230
Practice Address - Country:US
Practice Address - Phone:512-744-6000
Practice Address - Fax:512-225-6520
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX541988363LP0200X
TXAP121376364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3280315-02Medicaid