Provider Demographics
NPI:1851397046
Name:LIGHTFOOT, IDA MADOKA (RN, PMHNP)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:MADOKA
Last Name:LIGHTFOOT
Suffix:
Gender:F
Credentials:RN, PMHNP
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:M
Other - Last Name:ARMSTRONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, PMHNP
Mailing Address - Street 1:1241 FOREST PARK DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-2805
Mailing Address - Country:US
Mailing Address - Phone:817-821-9978
Mailing Address - Fax:
Practice Address - Street 1:6404 INTERNATIONAL PKWY STE 1010
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8346
Practice Address - Country:US
Practice Address - Phone:972-267-1988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX593409363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX368676801Medicaid
TXP94062OtherMEDICARE UPIN