Basic Information
| Provider Information | |||||||||
| NPI: | 1831672971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECLAN | ||||||||
| FirstName: | EDITH | ||||||||
| MiddleName: | NKEM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NWOBODO | ||||||||
| OtherFirstName: | EDTH | ||||||||
| OtherMiddleName: | NKEM | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 826 LA HACIENDA DR | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774062859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139096541 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6720 BERTNER AVE | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136668287 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2018 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WX0200X | 931021 | TX | Y | Nursing Service Providers | Registered Nurse | Oncology |
No ID Information.