Healthcare Provider Details

I. General information

NPI: 1083255533
Provider Name (Legal Business Name): CHUNG MEI PENG AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4145 TABERNASH
RICHARDSON TX
75082-3744
US

IV. Provider business mailing address

4145 TABERNASH
RICHARDSON TX
75082-3744
US

V. Phone/Fax

Practice location:
  • Phone: 469-867-5258
  • Fax:
Mailing address:
  • Phone: 469-867-5258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP143352
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: