Provider Demographics
NPI:1902277056
Name:ABAM, ADELINE ETOGHE (APRN-CNP)
Entity type:Individual
Prefix:
First Name:ADELINE
Middle Name:ETOGHE
Last Name:ABAM
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:ADELINE
Other - Middle Name:
Other - Last Name:ASANDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 2603
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2603
Mailing Address - Country:US
Mailing Address - Phone:817-569-4039
Mailing Address - Fax:817-810-3042
Practice Address - Street 1:3840 HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7277
Practice Address - Country:US
Practice Address - Phone:817-335-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129503363LP0808X
TX786779363LC0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8450NSOtherBCBS
TX8450NSOtherBCBS
TX455157ZUHKMedicare PIN