Healthcare Provider Details

I. General information

NPI: 1063193522
Provider Name (Legal Business Name): CARMEN LAKER OLOYA-EDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 PARK BEND DR STE 300
AUSTIN TX
78758-5674
US

IV. Provider business mailing address

2217 PARK BEND DR STE 300
AUSTIN TX
78758-5674
US

V. Phone/Fax

Practice location:
  • Phone: 512-382-1993
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1152665
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: