MEDICARE: MRS. GRACE MODUPE ODUNTAN FNP

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	363LF0000X	Family Nurse Practitioner	1061189	TX

General Provider Information

NPI Number	:	1962132662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GRACE MODUPE ODUNTAN FNP

Provider Business Mailing Address
First Line	:	16518 LACEY LN
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77489-3956
Country	:	US
Telephone Number	:	713-240-4045
Fax Number	:

Provider Business Practice Location Address
First Line	:	16518 LACEY LN
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77489-3956
Country	:	US
Telephone Number	:	713-240-4045
Fax Number	:

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

Provider Enumeration Date	:	06/15/2022
Last Update Date	:	06/15/2022

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