Provider Demographics
NPI:1912733163
Name:DERVIS, LINDA RENEE
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:RENEE
Last Name:DERVIS
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 1:1819 HOWTH AVE
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77051-3291
Mailing Address - Country:US
Mailing Address - Phone:832-921-3653
Mailing Address - Fax:
Practice Address - Street 1:1819 HOWTH AVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77051-3291
Practice Address - Country:US
Practice Address - Phone:832-921-3653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3747A0650X3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider