Provider Demographics
NPI:1528498433
Name:PAILES, MARY SAMANTHA (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SAMANTHA
Last Name:PAILES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N KIMBALL AVE SUITE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6173
Mailing Address - Country:US
Mailing Address - Phone:817-328-8376
Mailing Address - Fax:
Practice Address - Street 1:620 NORTH KIMBALL AVENUE
Practice Address - Street 2:SUITE100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6173
Practice Address - Country:US
Practice Address - Phone:817-328-8376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX709408363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health