Healthcare Provider Details

I. General information

NPI: 1871299263
Provider Name (Legal Business Name): STEPHANIE MAKUMI MORENO AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE WANGUI MAKUMI

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SCENIC DR STE 1114
GEORGETOWN TX
78626-7724
US

IV. Provider business mailing address

8240 N MOPAC EXPY STE 100
AUSTIN TX
78759-8869
US

V. Phone/Fax

Practice location:
  • Phone: 512-248-2200
  • Fax: 512-248-1950
Mailing address:
  • Phone: 512-610-5339
  • Fax: 512-407-9010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1108827
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: