MEDICARE: BETH WANGOMBE

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	AP129603	TX

General Provider Information

NPI Number	:	1457724502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH WANGOMBE

Provider Business Mailing Address
First Line	:	1380 RIVER BEND DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75247-4914
Country	:	US
Telephone Number	:	214-743-6146
Fax Number	:

Provider Business Practice Location Address
First Line	:	2384 HIGHWAY 287 N STE 206
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-9207
Country	:	US
Telephone Number	:	682-518-3334
Fax Number	:

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

Provider Enumeration Date	:	11/10/2015
Last Update Date	:	02/27/2024

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Directions to “ BETH WANGOMBE ” Practice Location

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