Provider Demographics
NPI:1144843384
Name:INNIS, PATRICIA KATHLEEN
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:KATHLEEN
Last Name:INNIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL CENTER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2821
Mailing Address - Country:US
Mailing Address - Phone:441-968-0936
Mailing Address - Fax:936-539-9685
Practice Address - Street 1:100 MEDICAL CENTER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2821
Practice Address - Country:US
Practice Address - Phone:441-968-0936
Practice Address - Fax:936-539-9685
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000173363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily