Provider Demographics
NPI:1710475298
Name:GISEMBA, EVERLINE NYASUGUTA
Entity Type:Individual
Prefix:
First Name:EVERLINE
Middle Name:NYASUGUTA
Last Name:GISEMBA
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 1:3424 TIPPERARY DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8016
Mailing Address - Country:US
Mailing Address - Phone:214-694-4703
Mailing Address - Fax:
Practice Address - Street 1:3424 TIPPERARY DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-8016
Practice Address - Country:US
Practice Address - Phone:214-694-4703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314447164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse