ITASCA HEALING MEDICAL PRACTICE
NPI 1023867546
Nurse Practitioner in Nacogdoches, TX

Q: What is Itasca Healing Medical Practice's NPI number?

The NPI number for Itasca Healing Medical Practice is 1023867546. It was assigned to this organization in the NPPES registry on May 16, 2024.

Q: What is Itasca Healing Medical Practice's specialty?

The primary specialty registered for this NPI is Nurse Practitioner with taxonomy code 363L00000X.

Active since May 16, 2024CLIA 45D2306063 · Waiver

223 KING ST, NACOGDOCHES, TX 75961(936) 622-0552(936) 622-0554 Get Directions Write a Review

NPPES record last updated: August 5, 2026. Verified against the NPPES registry weekly; last sync: October 25, 2026.

Record update history: Aug 5, 2026, Oct 2, 2024, May 16, 2024 (3 updates tracked since 2024).

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About Itasca Healing Medical Practice NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

ITASCA HEALING MEDICAL PRACTICE (NPI 1023867546) is a healthcare organization registered as a nurse practitioner in Nacogdoches, Texas and active in the NPI registry since May 2024. The organization holds a CLIA Waiver certificate valid through June 10, 2028 and lists Suzanna Itasca Fuller, Owner/ Provider, as its authorized official.

NPPES Registry Identity

NPI1023867546

Entity TypeOrganization

Primary Taxonomy363L00000X

Legal Business NameITASCA HEALING MEDICAL PRACTICE

Location Address223 KING STNacogdoches, TX 75961-4421

Mailing Address223 King StNacogdoches, TX 75961-4421 · (936) 622-0552 · Fax (936) 622-0554

Phone(936) 622-0552

Fax(936) 622-0554

Organization SubpartNo

Authorized OfficialSuzanna Itasca FullerOwner/ Provider · (936) 622-0552

Enumeration DateMay 16, 2024

Last NPPES UpdateAugust 5, 20263 updates tracked since enumeration

NPPES CertifiedAugust 5, 2026

✔ NPI 1023867546 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyNurse PractitionerPhysician Assistants & Advanced Practice Nursing Providers

Taxonomy Code363L00000X

Definition

(1) A registered nurse provider with a graduate degree in nursing prepared for advanced practice involving independent and interdependent decision making and direct accountability for clinical judgment across the health care continuum or in a certified specialty. (2) A registered nurse who has completed additional training beyond basic nursing education and who provides primary health care services in accordance with state nurse practice laws or statutes. Tasks performed by nurse practitioners vary with practice requirements mandated by geographic, political, economic, and social factors. Nurse practitioner specialists include, but are not limited to, family nurse practitioners, gerontological nurse practitioners, pediatric nurse practitioners, obstetric-gynecologic nurse practitioners, and school nurse practitioners.

223 KING ST, Nacogdoches, TX 75961

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Group Practice 1

Group TaxonomyThis provdier is a business group of one or more individual practitioners, all of who practice with the same area of specialization.193400000X SINGLE SPECIALTY GROUP

Medicare Participation & PECOS CMS

Medicare enrollment and the clinicians who bill Medicare through this organization, from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Itasca Healing Medical Practice is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Clinicians Billing Medicare Through This Organization

Medicare enrollment records show 1 clinician reassigns Medicare billing to Itasca Healing Medical Practice, which bills Medicare for the services this clinician delivers.

Clinician (1)

Suzanna Fuller, NURSE PRACTITIONER

Nurse Practitioner

NPI 1326504382

223 KING ST
Nacogdoches, TX 75961

(936) 622-0552

✔ PECOS✔ Accepts MedicareSame address

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 45D2306063

Itasca Healing Medical Practice · Nacogdoches, TX

Active · expires Jun 10, 2028

CLIA Number45D2306063

Laboratory TypePhysician Office

Certificate Effective DateJune 11, 2026

Certificate Expiration DateJune 10, 2028

Laboratory DirectorSuzanna Fuller

Laboratory Phone(936) 622-0552

Laboratory LocationItasca Healing Medical Practice223 King St, Nacogdoches, TX 75961

CLIA data matches this NPI record on: Address Name Phone

This certificate is issued to a laboratory to perform only waived tests.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Itasca Healing Medical Practice's NPI number?

The NPI number for Itasca Healing Medical Practice is 1023867546. It was assigned to this organization in the NPPES registry on May 16, 2024.

Where is Itasca Healing Medical Practice located?

Itasca Healing Medical Practice is located at 223 King St, Nacogdoches, TX 75961. The listed phone number is (936) 622-0552.

What is Itasca Healing Medical Practice's specialty?

The primary specialty registered for this NPI is Nurse Practitioner with taxonomy code 363L00000X.

Is Itasca Healing Medical Practice enrolled in Medicare?

Yes. Itasca Healing Medical Practice is registered in the Medicare PECOS enrollment system.

How many clinicians bill Medicare through Itasca Healing Medical Practice?

According to the CMS Revalidation Reassignment List (October 2026 release), 1 clinician (Nurse Practitioner) reassigns their Medicare billing to Itasca Healing Medical Practice. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Does Itasca Healing Medical Practice hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 45D2306063) is associated with this NPI, valid through June 10, 2028. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Itasca Healing Medical Practice was last updated on August 5, 2026. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 2 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.