MEDICARE: FATMATA PORREH BANGURA

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	164X00000X	Licensed Vocational Nurse	331890	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	331890	OTHER	TX	LICENSED VOCATIONAL NURSE

General Provider Information

NPI Number	:	1235611740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FATMATA PORREH BANGURA

Provider Business Mailing Address
First Line	:	16710 CHESHIRE PLACE DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-5210
Country	:	US
Telephone Number	:	832-306-0547
Fax Number	:

Provider Business Practice Location Address
First Line	:	16710 CHESHIRE PLACE DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-5210
Country	:	US
Telephone Number	:	832-306-0547
Fax Number	:

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

Provider Enumeration Date	:	08/30/2018
Last Update Date	:	08/30/2018

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