Healthcare Provider Details

I. General information

NPI: 1407624141
Provider Name (Legal Business Name): GENISA ESTELLE OGDEN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GENISA ESTELLE OGDEN PMHNP

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14185 FM 1008
DAYTON TX
77535-8276
US

IV. Provider business mailing address

14185 FM 1008
DAYTON TX
77535-8276
US

V. Phone/Fax

Practice location:
  • Phone: 702-762-8534
  • Fax:
Mailing address:
  • Phone: 702-762-8534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1142468
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: