Healthcare Provider Details

I. General information

NPI: 1154851129
Provider Name (Legal Business Name): OLIVIA CHINONSO IHEANACHO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 SPICEWOOD SPRINGS RD
AUSTIN TX
78759-8661
US

IV. Provider business mailing address

1430 COLLIER ST
AUSTIN TX
78704-2911
US

V. Phone/Fax

Practice location:
  • Phone: 512-732-2122
  • Fax: 512-732-2124
Mailing address:
  • Phone: 512-472-4357
  • Fax: 512-703-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number835635
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1105564
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: