Active NPI
Agnes Jeruto Mamboleo
- Licensed Practical Nurse
- Fort Worth, TX
National Provider Identifier
1750926630
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Licensed Practical Nurse
- License
- LP35237
- Practice address
- 4921 Woodmeadow Dr
Fort Worth, TX 76135-1824 - Phone
- (301) 204-6081
- NPI assigned
- Nov 14, 2019
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Licensed Practical Nurse | 164W00000X | LP35237 | MD | Primary |
Addresses
Primary practice location
4921 Woodmeadow Dr
Fort Worth, TX 76135-1824
Mailing address
4921 Woodmeadow Dr
Fort Worth, TX 76135-1824
Phone (301) 204-6081
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LP35237 | MD | MD | Licensed Practical Nurse |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1573689600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1573689600000",
"number": "1750926630",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4921 WOODMEADOW DR",
"city": "FORT WORTH",
"state": "TX",
"postal_code": "761351824",
"telephone_number": "301-204-6081"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4921 WOODMEADOW DR",
"city": "FORT WORTH",
"state": "TX",
"postal_code": "761351824",
"telephone_number": "301-204-6081"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MAMBOLEO",
"first_name": "AGNES",
"middle_name": "JERUTO",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2019-11-14",
"last_updated": "2019-11-14",
"status": "A"
},
"taxonomies": [
{
"code": "164W00000X",
"taxonomy_group": "",
"desc": "Licensed Practical Nurse",
"state": "MD",
"license": "LP35237",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fort Worth, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 14, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.