Healthcare Provider Details

I. General information

NPI: 1154198018
Provider Name (Legal Business Name): CLARE IME MBANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 12/11/2023
Certification Date: 12/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 E 8TH AVE
SPOKANE WA
99202-1201
US

IV. Provider business mailing address

5460 BABCOCK RD STE 120
SAN ANTONIO TX
78240-3400
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-5678
  • Fax:
Mailing address:
  • Phone: 210-996-5777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number1086771
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: