Healthcare Provider Details

I. General information

NPI: 1861975534
Provider Name (Legal Business Name): AGWESIP EMMACULATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6202 BALCONY LN
DALLAS TX
75241-5059
US

IV. Provider business mailing address

6202 BALCONY LN
DALLAS TX
75241-5059
US

V. Phone/Fax

Practice location:
  • Phone: 972-404-6542
  • Fax:
Mailing address:
  • Phone: 972-404-6542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberP62434
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: