Healthcare Provider Details

I. General information

NPI: 1104618594
Provider Name (Legal Business Name): WILFRED OMWANDO ONDIEKI REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 05/21/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 HULEN ST
FORT WORTH TX
76107-7276
US

IV. Provider business mailing address

710 BOONE TRL
MANSFIELD TX
76063-3414
US

V. Phone/Fax

Practice location:
  • Phone: 817-335-3022
  • Fax:
Mailing address:
  • Phone: 682-391-5002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number923413
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: