Provider Demographics
NPI:1821368713
Name:MPUTU, NAOMI
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:MPUTU
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 1:7609 MEADOWLARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-7939
Mailing Address - Country:US
Mailing Address - Phone:443-528-9366
Mailing Address - Fax:
Practice Address - Street 1:7609 MEADOWLARK DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-7939
Practice Address - Country:US
Practice Address - Phone:443-528-9366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY652275163W00000X
MDR196685163W00000X
TX1069023363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse