Provider Demographics
NPI:1902947120
Name:IMMANUEL, STELLA GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:STELLA
Middle Name:GRACE
Last Name:IMMANUEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STELLA
Other - Middle Name:A
Other - Last Name:GWANDIKU-AMBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:25231 ROESNER LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-5537
Mailing Address - Country:US
Mailing Address - Phone:281-506-7412
Mailing Address - Fax:281-530-2882
Practice Address - Street 1:25231 ROESNER LN
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-5537
Practice Address - Country:US
Practice Address - Phone:281-506-7412
Practice Address - Fax:281-530-2882
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS39942080A0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1545414Medicaid
LA5E068Medicare ID - Type Unspecified
LAOTH000Medicare UPIN