Healthcare Provider Details

I. General information

NPI: 1366192973
Provider Name (Legal Business Name): CHRISTINE ROSEANN IDEMUDIA APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2022
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8739 DAVIS BLVD STE 100
KELLER TX
76248-0309
US

IV. Provider business mailing address

8739 DAVIS BLVD STE 100
KELLER TX
76248-0309
US

V. Phone/Fax

Practice location:
  • Phone: 817-476-1226
  • Fax: 888-355-4603
Mailing address:
  • Phone: 817-476-1226
  • Fax: 888-355-4603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number67455
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number67455
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: