Provider Demographics
NPI:1336638253
Name:MONGARE, FRIDAH OBONYO (LVN)
Entity Type:Individual
Prefix:
First Name:FRIDAH
Middle Name:OBONYO
Last Name:MONGARE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 DEL PASO ST APT 132
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-5004
Mailing Address - Country:US
Mailing Address - Phone:469-427-6937
Mailing Address - Fax:
Practice Address - Street 1:605 DEL PASO ST APT 132
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-5004
Practice Address - Country:US
Practice Address - Phone:469-427-6937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX324819164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse