Provider Demographics
NPI:1356793509
Name:INDIVIDUAL
Entity type:Organization
Organization Name:INDIVIDUAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:PRISCA
Authorized Official - Middle Name:CHIOMA
Authorized Official - Last Name:UGHANZE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:817-908-7822
Mailing Address - Street 1:3500 TIMBERWOOD CIR APT 2137
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-3129
Mailing Address - Country:US
Mailing Address - Phone:817-908-7822
Mailing Address - Fax:
Practice Address - Street 1:3500 TIMBERWOOD CIR APT 2137
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-3129
Practice Address - Country:US
Practice Address - Phone:817-908-7822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)