Healthcare Provider Details

I. General information

NPI: 1295299048
Provider Name (Legal Business Name): MARY OKIOMAH MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 METRIC BLVD
AUSTIN TX
78758-8616
US

IV. Provider business mailing address

4495 WANDERING VINE TRL
ROUND ROCK TX
78665-1266
US

V. Phone/Fax

Practice location:
  • Phone: 512-840-1158
  • Fax:
Mailing address:
  • Phone: 512-840-1158
  • Fax: 512-777-5974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP139063
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: