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Organization
ITASCA HEALING MEDICAL PRACTICE
Active
Organization
ITASCA HEALING MEDICAL PRACTICE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SUZANNA ITASCA FULLER NP (OWNER/ PROVIDER)
(936) 622-0552
Entity
Organization
Contact information
Practice address
223 KING ST, NACOGDOCHES, TX 75961-4421
(936) 622-0552
(936) 622-0554
Mailing address
223 KING ST, NACOGDOCHES, TX 75961-4421
(936) 622-0552
(936) 622-0554
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
363L00000X
Nurse Practitioner
Primary
—
NULL
363L00000X
Nurse Practitioner
Primary
—
—
Other
Enumeration date
05/16/2024
Last updated
08/05/2026
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