Healthcare Provider Details

I. General information

NPI: 1891711552
Provider Name (Legal Business Name): KIRSTEN ANGELIQUE WADE PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIRSTEN ANGELIQUE BENFORD

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6109 S COOPER ST
ARLINGTON TX
76001-5814
US

IV. Provider business mailing address

803 SIERRA AVE
MANSFIELD TX
76063-1887
US

V. Phone/Fax

Practice location:
  • Phone: 866-492-5008
  • Fax:
Mailing address:
  • Phone: 972-249-5561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP122926
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: