| Organization Name: | FAITH MEDICAL CLINIC, PLLC |
| NPI Number: | 1417368168 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | GLORIA R FULLER (OWNER) |
| Mailing Address: | 1619 4th Ave Canyon |
| State: | TX US |
| Postal Code: | 790153824 |
| Phone Number: | 8065574138 |
| Fax Number: | 8065574165 |
| NPI Enumeration Date: | 05/15/2014 |
| NPI Last Update Date: | 12/12/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | AP118557 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TX |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |