MEDICARE: IFEANYI DURUEWURU FNP-C

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	207Q00000X	Family Medicine Physician	AP141138	TX
2	363LA2200X	Adult Health Nurse Practitioner	AP141138	TX
3	363LF0000X	Family Nurse Practitioner	AP141138	TX

General Provider Information

NPI Number	:	1609432764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IFEANYI DURUEWURU FNP-C

Provider Business Mailing Address
First Line	:	3132 MATLOCK RD STE 311
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76015-2922
Country	:	US
Telephone Number	:	214-906-5427
Fax Number	:

Provider Business Practice Location Address
First Line	:	3132 MATLOCK RD STE 311
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76015-2922
Country	:	US
Telephone Number	:	214-906-5427
Fax Number	:

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

Provider Enumeration Date	:	05/14/2019
Last Update Date	:	09/24/2020

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