Provider Demographics
NPI:1780710319
Name:LIGHTHOUSE HEALTH CLINIC
Entity type:Organization
Organization Name:LIGHTHOUSE HEALTH CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:512-528-9996
Mailing Address - Street 1:601 E WHITESTONE BLVD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-9015
Mailing Address - Country:US
Mailing Address - Phone:512-528-9996
Mailing Address - Fax:512-528-9070
Practice Address - Street 1:601 E WHITESTONE BLVD
Practice Address - Street 2:SUITE 308
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-9015
Practice Address - Country:US
Practice Address - Phone:512-528-9996
Practice Address - Fax:512-528-9070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX629991363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX98261OtherNATIONAL CERTIFICATION PN
TX02468OtherPRESCRIPTIVE AUTHORITY #
TX629991OtherADVANCED PRACTICE NURSE