Basic Information
| Provider Information | |||||||||
| NPI: | 1851458038 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS MEDICAL CENTER DALLAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5060 WATEKA DR | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752094825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143532775 | ||||||||
| FaxNumber: | 2144565071 | ||||||||
| Practice Location | |||||||||
| Address1: | 1935 MOTOR ST | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144565614 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ATHRE | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | DETAMORE | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 2144565614 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN, MSN CPNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | 630600 | TX | Y | Hospitals | General Acute Care Hospital | Children |
No ID Information.