Healthcare Provider Details

I. General information

NPI: 1760899751
Provider Name (Legal Business Name): SHAUNA LEIGH OKONGO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 7TH AVE
FORT WORTH TX
76104-2733
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-4054
  • Fax: 682-885-7497
Mailing address:
  • Phone: 682-885-1855
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP125947
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: