Provider Demographics
NPI:1174181754
Name:NKWANTABISA, URSULA N
Entity Type:Individual
Prefix:
First Name:URSULA
Middle Name:N
Last Name:NKWANTABISA
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 1:1704 CARTIER PL
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-5730
Mailing Address - Country:US
Mailing Address - Phone:850-687-7890
Mailing Address - Fax:
Practice Address - Street 1:1704 CARTIER PL
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-5730
Practice Address - Country:US
Practice Address - Phone:850-687-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL235901376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNAOtherNA