MEDICARE: MRS. MARYGORRETH SAMANYA SSENTAMU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	225371	TX

General Provider Information

NPI Number	:	1114420338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARYGORRETH SAMANYA SSENTAMU

Provider Business Mailing Address
First Line	:	5183 MEADOW CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-3865
Country	:	US
Telephone Number	:	682-429-8898
Fax Number	:

Provider Business Practice Location Address
First Line	:	5183 MEADOW CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-3865
Country	:	US
Telephone Number	:	682-429-8898
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2018
Last Update Date	:	03/14/2018

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