Provider Demographics
NPI:1003009580
Name:IDICULA, MIMI SONG (NP)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:SONG
Last Name:IDICULA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6161 N STATE HIGHWAY 161
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2220
Mailing Address - Country:US
Mailing Address - Phone:972-258-7499
Mailing Address - Fax:972-257-0897
Practice Address - Street 1:6161 N STATE HIGHWAY 161
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2220
Practice Address - Country:US
Practice Address - Phone:972-258-7499
Practice Address - Fax:972-257-0897
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10049111N00000X
TXAP137449363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP137449OtherNURSE PRACTITIONER