Individual
IDA MADOKA LIGHTFOOT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
RN, PMHNP
Contact information
Practice address
6404 INTERNATIONAL PKWY STE 1010, PLANO, TX 75093-8346
(972) 267-1988
Mailing address
1241 FOREST PARK DR, WEATHERFORD, TX 76087-2805
(817) 821-9978
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
593409
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
368676801
—
TX
01
—
P94062
MEDICARE UPIN
TX
Enumeration date
06/22/2005
Last updated
07/19/2021
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