MEDICARE: GRACE NWANNE IGBUDU

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2023019806	TX

General Provider Information

NPI Number	:	1205518784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE NWANNE IGBUDU

Provider Business Mailing Address
First Line	:	6777 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7155
Country	:	US
Telephone Number	:	682-900-4246
Fax Number	:

Provider Business Practice Location Address
First Line	:	6777 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7155
Country	:	US
Telephone Number	:	817-670-4464
Fax Number	:

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

Provider Enumeration Date	:	08/03/2023
Last Update Date	:	10/01/2024

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Directions to “ GRACE NWANNE IGBUDU ” Practice Location

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