Healthcare Provider Details

I. General information

NPI: 1174026249
Provider Name (Legal Business Name): GRACE A UWAGBAI LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 03/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5828 SOMERTON DR
GRAND PRAIRIE TX
75052-8590
US

IV. Provider business mailing address

5828 SOMERTON DR
GRAND PRAIRIE TX
75052-8590
US

V. Phone/Fax

Practice location:
  • Phone: 817-983-9986
  • Fax:
Mailing address:
  • Phone: 817-983-9986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number208133
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: