Healthcare Provider Details

I. General information

NPI: 1609601491
Provider Name (Legal Business Name): VIVIAN IJEMABA OSEMENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 W 35TH ST
AUSTIN TX
78703-1203
US

IV. Provider business mailing address

4219 N SUMMERCREST LOOP
ROUND ROCK TX
78681-1087
US

V. Phone/Fax

Practice location:
  • Phone: 512-454-4731
  • Fax:
Mailing address:
  • Phone: 512-740-5441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number888034
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: