Provider Demographics
NPI:1447624853
Name:MBAKU, GWENDOLINE (FNP)
Entity type:Individual
Prefix:MRS
First Name:GWENDOLINE
Middle Name:
Last Name:MBAKU
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15175 PALO PINTO DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-5556
Mailing Address - Country:US
Mailing Address - Phone:214-682-5236
Mailing Address - Fax:
Practice Address - Street 1:3133 E LEMMON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-1411
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:401-216-3854
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129670363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3567679Medicaid
470263ZHSBMedicare PIN