Healthcare Provider Details

I. General information

NPI: 1376023473
Provider Name (Legal Business Name): ELLAH GWANYANYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 LA FALDA # SA
SAN ANTONIO TX
78258-2930
US

IV. Provider business mailing address

903 LA FALDA # SA
SAN ANTONIO TX
78258-2930
US

V. Phone/Fax

Practice location:
  • Phone: 510-459-2383
  • Fax:
Mailing address:
  • Phone: 510-459-2383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number898596
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: