Healthcare Provider Details

I. General information

NPI: 1497037725
Provider Name (Legal Business Name): MOBOLANLE A. FAGBEMI APRN. FNP-C, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N 11TH ST
BEAUMONT TX
77702-1804
US

IV. Provider business mailing address

PO BOX 66308
HOUSTON TX
77266-6308
US

V. Phone/Fax

Practice location:
  • Phone: 832-548-5000
  • Fax:
Mailing address:
  • Phone: 832-548-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP119341
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP119341
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: