Provider Demographics
NPI:1619477205
Name:KAMWARO, MERCY
Entity Type:Individual
Prefix:
First Name:MERCY
Middle Name:
Last Name:KAMWARO
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 1:3817 VICTORIA CT
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-6159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6337 RIPPLE SPRINGS DR
Practice Address - Street 2:
Practice Address - City:WATAUGA
Practice Address - State:TX
Practice Address - Zip Code:76148-1313
Practice Address - Country:US
Practice Address - Phone:682-557-6974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214687251E00000X, 251J00000X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX613373928Medicaid