Provider Demographics
NPI:1578862694
Name:MWANIKI, NELLY WAKARIA (FNP-C)
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:WAKARIA
Last Name:MWANIKI
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 BOAT CLUB RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-5285
Mailing Address - Country:US
Mailing Address - Phone:817-237-0515
Mailing Address - Fax:
Practice Address - Street 1:4701 BOAT CLUB RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-5285
Practice Address - Country:US
Practice Address - Phone:817-237-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX732298363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX277050YKPWMedicare PIN