Provider Demographics
NPI:1992102149
Name:BEDARD, DORACE LISA (NP)
Entity type:Individual
Prefix:MS
First Name:DORACE
Middle Name:LISA
Last Name:BEDARD
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 1:3227 MOSS ST
Mailing Address - Street 2:
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-4612
Mailing Address - Country:US
Mailing Address - Phone:409-935-3423
Mailing Address - Fax:
Practice Address - Street 1:5509 ATTWATER AVE
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539-4157
Practice Address - Country:US
Practice Address - Phone:409-948-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP114077363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health