Provider Demographics
NPI:1841724770
Name:HERITAGE FAMILY MEDICINE AND AESTHETICS
Entity type:Organization
Organization Name:HERITAGE FAMILY MEDICINE AND AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:NEGRON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:817-354-7999
Mailing Address - Street 1:4214 GATEWAY DR STE 150
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-7905
Mailing Address - Country:US
Mailing Address - Phone:817-354-7999
Mailing Address - Fax:
Practice Address - Street 1:4214 GATEWAY DR STE 150
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-7905
Practice Address - Country:US
Practice Address - Phone:817-354-7999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133805363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty