Healthcare Provider Details

I. General information

NPI: 1245704683
Provider Name (Legal Business Name): DIANA KIPCHILAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 01/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 E LAMAR BLVD STE 350
ARLINGTON TX
76011-4157
US

IV. Provider business mailing address

4055 VALLEY VIEW LN STE 400
DALLAS TX
75244-5071
US

V. Phone/Fax

Practice location:
  • Phone: 682-236-5770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP138404
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: