Provider Demographics
NPI:1215592274
Name:TAKUGLADYSTABE, FNU
Entity Type:Individual
Prefix:
First Name:FNU
Middle Name:
Last Name:TAKUGLADYSTABE
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 1:9393 SKILLMAN ST APT 1822
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-7390
Mailing Address - Country:US
Mailing Address - Phone:469-445-5986
Mailing Address - Fax:
Practice Address - Street 1:9393 SKILLMAN ST APT 1822
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-7390
Practice Address - Country:US
Practice Address - Phone:469-445-5986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX346685164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse