Provider Demographics
NPI:1790061315
Name:PROVIDENCE WELLNESS INC
Entity Type:Organization
Organization Name:PROVIDENCE WELLNESS INC
Other - Org Name:PROVIDENCE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:AKUNNA
Authorized Official - Last Name:EKE-HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MSC, ANP-C
Authorized Official - Phone:281-920-0344
Mailing Address - Street 1:13155 WESTHEIMER ROAD
Mailing Address - Street 2:SUITE #133
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077
Mailing Address - Country:US
Mailing Address - Phone:281-920-0344
Mailing Address - Fax:281-920-0263
Practice Address - Street 1:13155 WESTHEIMER ROAD
Practice Address - Street 2:SUITE #133
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077
Practice Address - Country:US
Practice Address - Phone:281-920-0344
Practice Address - Fax:281-920-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX801287323261Q00000X
TX363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB149978Medicare UPIN
TXTXB149977Medicare PIN