Provider Demographics
NPI:1396154068
Name:KIAWU, FREDICA
Entity type:Individual
Prefix:
First Name:FREDICA
Middle Name:
Last Name:KIAWU
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 1:1400 PARKWOOD TRAIL
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149
Mailing Address - Country:US
Mailing Address - Phone:214-753-9396
Mailing Address - Fax:972-222-9039
Practice Address - Street 1:1400 PARKWOOD TRAIL
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149
Practice Address - Country:US
Practice Address - Phone:214-753-9396
Practice Address - Fax:972-222-9039
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139977310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility