Healthcare Provider Details

I. General information

NPI: 1619440450
Provider Name (Legal Business Name): WISHING WELL CHILDREN'S CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1259 FM 1463 SUITE 300
KATY TX
77494
US

IV. Provider business mailing address

1259 FM 1463 SUITE 300
KATY TX
77494
US

V. Phone/Fax

Practice location:
  • Phone: 832-856-4600
  • Fax:
Mailing address:
  • Phone: 832-856-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROSABELLE VIA MCCONKEY
Title or Position: PEDIATRICIAN
Credential: MD
Phone: 832-856-4600