Healthcare Provider Details

I. General information

NPI: 1407745607
Provider Name (Legal Business Name): ABIMBOLA OLUFUNKE FAGUN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W EVERMAN PKWY
FORT WORTH TX
76134
US

IV. Provider business mailing address

1740 W EVERMAN PKWY
FORT WORTH TX
76134
US

V. Phone/Fax

Practice location:
  • Phone: 732-882-2418
  • Fax:
Mailing address:
  • Phone: 732-882-2418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number26NR12599800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number26NR12599800
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR12599800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: