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Organization
SOUTH LOOP 12 MEDICAL CLINIC LLC
Active
Organization
SOUTH LOOP 12 MEDICAL CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. CONNIE FRANCES NELLUM MS, APRN-C (FAMILY NURSE PACTITIONE CERTIFIED)
(214) 398-4157
Entity
Organization
Contact information
Practice address
3232 GREAT TRINITY FOREST WAY, STE. 102, DALLAS, TX 75216-7732
(214) 398-4157
(214) 398-4326
Mailing address
3232 GREAT TRINITY FOREST WAY, STE. 102, DALLAS, TX 75216-7732
(214) 398-4157
(214) 398-4326
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
528675
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
018919303
—
TX
01
—
5608640
FIRST HEALTH PROVIDER ID
TX
01
—
7438197
AETNA PROVIDER ID#
TX
01
—
8N8001
BCBC PROVIDER ID#
TX
Enumeration date
11/01/2006
Last updated
10/09/2014
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