MEDICARE: MARY ORISAFUNMI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	665977	TX

General Provider Information

NPI Number	:	1063067338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ORISAFUNMI

Provider Business Mailing Address
First Line	:	1155 DAIRY ASHFORD RD STE 560
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77079-3035
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7418 TETELA DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-3609
Country	:	US
Telephone Number	:	832-668-0953
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2019
Last Update Date	:	08/05/2019

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Directions to “ MARY ORISAFUNMI ” Practice Location

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