Provider Demographics
NPI:1194303164
Name:MUGO, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:MUGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13225 SETTLERS TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5706
Mailing Address - Country:US
Mailing Address - Phone:919-384-5393
Mailing Address - Fax:
Practice Address - Street 1:1150 WHITLEY RD
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3038
Practice Address - Country:US
Practice Address - Phone:817-431-2518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA0060050642376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNA0060050642OtherCNA CERTIFICATE