Provider Demographics
NPI:1528346855
Name:MAMBO, EVELYN TETANG (NP)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:TETANG
Last Name:MAMBO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20326 BANDERA LAKE LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-1505
Mailing Address - Country:US
Mailing Address - Phone:513-328-0534
Mailing Address - Fax:
Practice Address - Street 1:20326 BANDERA LAKE LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-1505
Practice Address - Country:US
Practice Address - Phone:513-328-5034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH348189163WM0705X
TXAPI43791363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11416731Medicaid