Individual
STEPHANIE LARGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
855 MONTGOMERY ST, FORT WORTH, TX 76107-2553
(817) 735-2660
Mailing address
855 MONTGOMERY ST, FORT WORTH, TX 76107-2553
(817) 735-5058
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
836232
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
325708101
—
TX
05
—
325708103
—
TX
01
—
8025ND
BCBS
TX
01
—
8364NJ
BCBS
TX
Enumeration date
08/14/2013
Last updated
11/10/2017
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