MEDICARE: URSULA N NKWANTABISA

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	376J00000X	Homemaker	235901	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NA	OTHER	FL	NA

General Provider Information

NPI Number	:	1174181754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	URSULA N NKWANTABISA

Provider Business Mailing Address
First Line	:	1704 CARTIER PL
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-5730
Country	:	US
Telephone Number	:	850-687-7890
Fax Number	:

Provider Business Practice Location Address
First Line	:	1704 CARTIER PL
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-5730
Country	:	US
Telephone Number	:	850-687-7890
Fax Number	:

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

Provider Enumeration Date	:	05/30/2019
Last Update Date	:	05/30/2019

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