MEDICARE: PRINCESS KUKUA AHEDOR

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP139886	TX
2	363LF0000X	Family Nurse Practitioner	AP139886	TX

General Provider Information

NPI Number	:	1215401906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRINCESS KUKUA AHEDOR

Provider Business Mailing Address
First Line	:	4500 CARTER CREEK PKWY STE 101B
Second Line	:
City	:	BRYAN
State	:	TX
Zip	:	77802-4464
Country	:	US
Telephone Number	:	915-532-0010
Fax Number	:	979-316-1851

Provider Business Practice Location Address
First Line	:	2100 GEORGE DIETER DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-3815
Country	:	US
Telephone Number	:	915-955-2238
Fax Number	:

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

Provider Enumeration Date	:	01/15/2019
Last Update Date	:	12/09/2025

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Directions to “ PRINCESS KUKUA AHEDOR ” Practice Location

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