Healthcare Provider Details

I. General information

NPI: 1417658345
Provider Name (Legal Business Name): OMOTAYO RUKAYAT AUNDE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2023
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 AIRPORT FWY STE 230
BEDFORD TX
76021-6091
US

IV. Provider business mailing address

2507 TILDEN LN
VENUS TX
76084-3363
US

V. Phone/Fax

Practice location:
  • Phone: 817-354-5200
  • Fax:
Mailing address:
  • Phone: 862-271-9164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1098864
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: