Healthcare Provider Details

I. General information

NPI: 1770330326
Provider Name (Legal Business Name): MRS. ABOSEDE OLUBUNMI GBAKINRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N WATSON RD STE 190
ARLINGTON TX
76006-6225
US

IV. Provider business mailing address

3060 S CAMINO LAGOS
GRAND PRAIRIE TX
75054-6743
US

V. Phone/Fax

Practice location:
  • Phone: 817-637-2701
  • Fax:
Mailing address:
  • Phone: 817-637-2701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1077320
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1077320
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: