Healthcare Provider Details

I. General information

NPI: 1952574055
Provider Name (Legal Business Name): YOLANDE MFONDOUM PENGETNZE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W UNIVERSITY DR
PROSPER TX
75078-9805
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 945-204-4100
  • Fax: 682-885-1903
Mailing address:
  • Phone: 682-885-6483
  • Fax: 682-885-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN1059
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberN1059
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: