Provider Demographics
NPI:1073013942
Name:GILMORE-MBUGUA, ANTONINA NJERI
Entity Type:Individual
Prefix:MISS
First Name:ANTONINA
Middle Name:NJERI
Last Name:GILMORE-MBUGUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14501 MONTFORT DR APT 207
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8548
Mailing Address - Country:US
Mailing Address - Phone:214-886-5783
Mailing Address - Fax:
Practice Address - Street 1:14501 MONTFORT DR APT 207
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-8548
Practice Address - Country:US
Practice Address - Phone:214-886-5783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-17
Last Update Date:2018-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX328292164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty