MEDICARE: MONA KIDWELL N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	508280	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P01095012	OTHER	TX	RAIL ROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	88N956	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043571243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONA KIDWELL N.P.

Provider Business Mailing Address
First Line	:	2785 GULF FWY S
Second Line	:	SUITE 115
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-4979
Country	:	US
Telephone Number	:	832-816-1370
Fax Number	:

Provider Business Practice Location Address
First Line	:	2785 GULF FWY S
Second Line	:	SUITE 115
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-4979
Country	:	US
Telephone Number	:	832-816-1370
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2012
Last Update Date	:	06/07/2015

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Directions to “ MONA KIDWELL N.P.” Practice Location

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