MEDICARE: BERI DIANE FONYUY BAMNJO

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	163WS0200X	School Registered Nurse	788476	TX
2	163WC0200X	Critical Care Medicine Registered Nurse	788476	TX
3	367500000X	Certified Registered Nurse Anesthetist	1127553	TX

General Provider Information

NPI Number	:	1972217016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERI DIANE FONYUY BAMNJO

Provider Business Mailing Address
First Line	:	4831 ASHLEY HOPE DR
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-1945
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1504 TAUB LOOP, DEPT OF ANESTHESIA, 4TH FL.
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-1608
Country	:	US
Telephone Number	:	713-873-2860
Fax Number	:

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

Provider Enumeration Date	:	01/12/2023
Last Update Date	:	03/23/2026

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