# ITASCA HEALING MEDICAL PRACTICE

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1023867546
- **Authorized official:** SUZANNA ITASCA FULLER NP (OWNER/ PROVIDER)
- **Authorized official phone:** (936) 622-0552

## Contact information

- **Practice address:** 223 KING ST, NACOGDOCHES, TX 75961-4421
- **Practice address phone:** (936) 622-0552
- **Practice address fax:** (936) 622-0554
- **Mailing address:** 223 KING ST, NACOGDOCHES, TX 75961-4421
- **Mailing address phone:** (936) 622-0552
- **Mailing address fax:** (936) 622-0554

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 363L00000X | Nurse Practitioner | — | NULL | Yes |
| 363L00000X | Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 05/16/2024
- **Last updated:** 08/05/2026