Healthcare Provider Details

I. General information

NPI: 1235964685
Provider Name (Legal Business Name): MONIQUE UKPONG APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MONIQUE POULIOT

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7033 BRYANT IRVIN RD STE 100
FORT WORTH TX
76132-4276
US

IV. Provider business mailing address

3535 BLUFFS LN APT 12208
GRAPEVINE TX
76051-1238
US

V. Phone/Fax

Practice location:
  • Phone: 469-600-0802
  • Fax:
Mailing address:
  • Phone: 469-600-0802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1152827
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: