Provider Demographics
NPI:1043571243
Name:KIDWELL, MONA (NP)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:
Last Name:KIDWELL
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 1:2785 GULF FWY S
Mailing Address - Street 2:SUITE 115
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-4979
Mailing Address - Country:US
Mailing Address - Phone:832-816-1370
Mailing Address - Fax:
Practice Address - Street 1:2785 GULF FWY S
Practice Address - Street 2:SUITE 115
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-4979
Practice Address - Country:US
Practice Address - Phone:832-816-1370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2015-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX508280363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88N956OtherBCBS
TX3031130-01Medicaid
TX2035487-02Medicaid
TXP01095012OtherRAIL ROAD MEDICARE
TX88N956OtherBCBS
TX3031130-01Medicaid