Healthcare Provider Details

I. General information

NPI: 1962919829
Provider Name (Legal Business Name): GLADYS WANJIKU KINYUA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2018
Last Update Date: 01/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 BROKEN SPOKE DR
LITTLE ELM TX
75068-5951
US

IV. Provider business mailing address

1004 BROKEN SPOKE DR
LITTLE ELM TX
75068-5951
US

V. Phone/Fax

Practice location:
  • Phone: 469-268-4626
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number853518
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: