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NPI Code Detail

MEDICARE: IDA MADOKA LIGHTFOOT RN, PMHNP

MEDICARE: IDA MADOKA LIGHTFOOT RN, PMHNP
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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner593409TX

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2P94062OTHERTXMEDICARE UPIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1851397046
Entity Type Code : Individual
Provider Name (Legal Business Name) : IDA MADOKA LIGHTFOOT RN, PMHNP
Provider Business Mailing Address
First Line : 1241 FOREST PARK DR
Second Line :
City : WEATHERFORD
State : TX
Zip : 76087-2805
Country : US
Telephone Number : 817-821-9978
Fax Number :
Provider Business Practice Location Address
First Line : 6404 INTERNATIONAL PKWY STE 1010
Second Line :
City : PLANO
State : TX
Zip : 75093-8346
Country : US
Telephone Number : 972-267-1988
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/22/2005
Last Update Date : 07/19/2021

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