Provider Demographics
NPI:1912417858
Name:MBA, AKENJEM EBONG (NP)
Entity Type:Individual
Prefix:
First Name:AKENJEM
Middle Name:EBONG
Last Name:MBA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 ASKEW DR
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-0179
Mailing Address - Country:US
Mailing Address - Phone:404-325-8552
Mailing Address - Fax:
Practice Address - Street 1:1902 COUNTRY CLUB DR STE 160
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-5823
Practice Address - Country:US
Practice Address - Phone:214-606-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135083363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine