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General NPI Number Information
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NPI Number | 1851721518
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Entity Type | Organization
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Legal Business Name | WISH MEMA
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Dates
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Enumeration Date | 11/17/2013
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Last Update Date | 11/17/2013
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Provider Practice Location Address
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Address Line | 1433 WIND DANCER TRL
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City | FORT WORTH
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State | TX
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Zip | 76131-5416
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Country | US
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Telephone | 469-223-9489
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Fax |
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Provider Business Mailing Address
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Address Line | 1433 WIND DANCER TRL
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City | FORT WORTH
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State | TX
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Zip | 76131-5416
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | WISH MEMA
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Credential | ACNP
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Telephone | 469-223-9489
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 742276
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License Number State | TX
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