Itasca Healing Medical Practice

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

Legal business name

ITASCA HEALING MEDICAL PRACTICE

Practice address

223 King St
Nacogdoches, TX 75961-4421

Phone

(936) 622-0552

Fax

(936) 622-0554

NPI assigned

May 16, 2024

Last updated

Aug 5, 2026By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Suzanna Itasca Fuller, NPNPI 1326504382

Title

Owner/ Provider

Phone

(936) 622-0552

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Suzanna Fuller, NURSE PRACTITIONER

  • Family Nurse Practitioner
  • Nacogdoches, TX
  • NPI 1326504382
  Medicare reassignment NPD Authorized official
• Luke Johnson, M.D., M.P.H.

  • Family Medicine Physician
  • Lufkin, TX
  • NPI 1457702623
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1715817600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1785888000000",
    "number": "1023867546",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "223 KING ST",
            "city": "NACOGDOCHES",
            "state": "TX",
            "postal_code": "759614421",
            "telephone_number": "936-622-0552",
            "fax_number": "936-622-0554"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "223 KING ST",
            "city": "NACOGDOCHES",
            "state": "TX",
            "postal_code": "759614421",
            "telephone_number": "936-622-0552",
            "fax_number": "936-622-0554"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ITASCA HEALING MEDICAL PRACTICE",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-05-16",
        "last_updated": "2026-08-05",
        "certification_date": "2026-08-05",
        "status": "A",
        "authorized_official_last_name": "FULLER",
        "authorized_official_first_name": "SUZANNA",
        "authorized_official_middle_name": "ITASCA",
        "authorized_official_title_or_position": "OWNER/ PROVIDER",
        "authorized_official_telephone_number": "936-622-0552",
        "authorized_official_credential": "NP"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Tori Alayne Jeans

• Nurse Practitioner in Nacogdoches, TX
• Providers in Nacogdoches, TX by specialty
• Nurse Practitioner in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 5, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.