Healthcare Provider Details

I. General information

NPI: 1861027419
Provider Name (Legal Business Name): MUSSIE FUTWI MEBRAHTU FAMILY NURSE PRAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 CANTERBURY CT
MIDLOTHIAN TX
76065-1417
US

IV. Provider business mailing address

214 CANTERBURY CT
MIDLOTHIAN TX
76065-1417
US

V. Phone/Fax

Practice location:
  • Phone: 469-688-9765
  • Fax:
Mailing address:
  • Phone: 469-688-9765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP145162
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: