Healthcare Provider Details

I. General information

NPI: 1386021186
Provider Name (Legal Business Name): ONONGAYA CALLY NWANYANWU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10209 BLACK HICKORY RD
DALLAS TX
75243-5101
US

IV. Provider business mailing address

10209 BLACK HICKORY RD
DALLAS TX
75243-5101
US

V. Phone/Fax

Practice location:
  • Phone: 214-724-9449
  • Fax: 469-330-1477
Mailing address:
  • Phone: 214-724-9449
  • Fax: 469-330-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP128064
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP128064
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP128064
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: