MEDICARE: ELO EDITH OMAKOR NURSE PRACTITIONER

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	AP135575	TX
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	847722	NV

General Provider Information

NPI Number	:	1841701323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELO EDITH OMAKOR NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	PO BOX 1805
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-0017
Country	:	US
Telephone Number	:	682-272-5143
Fax Number	:	972-440-2057

Provider Business Practice Location Address
First Line	:	215 DALTON DR
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-4454
Country	:	US
Telephone Number	:	682-272-5143
Fax Number	:

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

Provider Enumeration Date	:	10/24/2017
Last Update Date	:	04/11/2022

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