Provider Demographics
NPI:1306110366
Name:RICHARDSON, JANICE RENEA (AGNP)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:RENEA
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9229 LBJ FWY
Mailing Address - Street 2:ATTN: POST ACUTE
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3405
Mailing Address - Country:US
Mailing Address - Phone:682-236-3656
Mailing Address - Fax:214-570-1692
Practice Address - Street 1:1350 E LANCASTER AVE STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-6671
Practice Address - Country:US
Practice Address - Phone:817-702-8391
Practice Address - Fax:817-702-4102
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAP117208363LA2200X
TX601924363LG0600X, 363LP2300X
TXAP117208363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8445NJOtherBCBS
TX8920NKOtherBCBS
TX340549001Medicaid
TX340549003Medicaid
TX340549003Medicaid
TX373803YPF6Medicare PIN
TX373803YKPWMedicare PIN
TX340549001Medicaid
TX373803YKP5Medicare PIN