Healthcare Provider Details

I. General information

NPI: 1174372288
Provider Name (Legal Business Name): FORTUNE UWA-NDUKWE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11623 ANGUS RD # E20
AUSTIN TX
78759-4003
US

IV. Provider business mailing address

604 WILTSHIRE DR
HUTTO TX
78634-5739
US

V. Phone/Fax

Practice location:
  • Phone: 512-827-7011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number23-288129
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: