Healthcare Provider Details

I. General information

NPI: 1235561663
Provider Name (Legal Business Name): HENRY AKOH WANTCHAMI FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9709 BRUTON RD
DALLAS TX
75217-2704
US

IV. Provider business mailing address

12377 MERIT DR STE 300
DALLAS TX
75251-3126
US

V. Phone/Fax

Practice location:
  • Phone: 972-288-2844
  • Fax:
Mailing address:
  • Phone: 972-957-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP123816
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number760471
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: