Healthcare Provider Details

I. General information

NPI: 1902947120
Provider Name (Legal Business Name): STELLA GRACE IMMANUEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STELLA A GWANDIKU-AMBE MD

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25231 ROESNER LN
KATY TX
77494-5537
US

IV. Provider business mailing address

25231 ROESNER LN
KATY TX
77494-5537
US

V. Phone/Fax

Practice location:
  • Phone: 281-506-7412
  • Fax: 281-530-2882
Mailing address:
  • Phone: 281-506-7412
  • Fax: 281-530-2882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberS3994
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberS3994
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: