Provider Demographics
NPI:1629559919
Name:NDIP, MOURINE ARA-EBANGA
Entity Type:Individual
Prefix:
First Name:MOURINE
Middle Name:ARA-EBANGA
Last Name:NDIP
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 1:125 BISON LN
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-3763
Mailing Address - Country:US
Mailing Address - Phone:256-468-9514
Mailing Address - Fax:
Practice Address - Street 1:8700 CROWNHILL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1128
Practice Address - Country:US
Practice Address - Phone:210-824-5530
Practice Address - Fax:210-824-5323
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX318094164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse