Provider Demographics
NPI:1386385623
Name:MINICK, COURTNEY (FNP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MINICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 CALDBECK LN
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-6004
Mailing Address - Country:US
Mailing Address - Phone:832-405-3932
Mailing Address - Fax:
Practice Address - Street 1:1726 CALDBECK LN
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-6004
Practice Address - Country:US
Practice Address - Phone:832-405-3932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2023-01-25
Deactivation Date:2023-01-10
Deactivation Code:
Reactivation Date:2023-01-24
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX1095935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program