Individual
AGNES JERUTO MAMBOLEO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
4921 WOODMEADOW DR, FORT WORTH, TX 76135-1824
(301) 204-6081
Mailing address
4921 WOODMEADOW DR, FORT WORTH, TX 76135-1824
(301) 204-6081
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
LP35237
MD
Other
Enumeration date
11/14/2019
Last updated
11/14/2019
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