MEDICARE: KEYNA OMENUKOR

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0024286045	VA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP61500520	WA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP128934	TX
4	363LF0000X	Family Nurse Practitioner	AP128934	TX

General Provider Information

NPI Number	:	1215307715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEYNA OMENUKOR

Provider Business Mailing Address
First Line	:	1675 REPUBLIC PKWY STE 190
Second Line	:
City	:	MESQUITE
State	:	TX
Zip	:	75150-6902
Country	:	US
Telephone Number	:	972-576-7399
Fax Number	:	972-476-0006

Provider Business Practice Location Address
First Line	:	1675 REPUBLIC PKWY STE 190
Second Line	:
City	:	MESQUITE
State	:	TX
Zip	:	75150-6902
Country	:	US
Telephone Number	:	972-576-7399
Fax Number	:	972-476-0006

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

Provider Enumeration Date	:	09/28/2015
Last Update Date	:	10/02/2024

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Directions to “ KEYNA OMENUKOR ” Practice Location

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