Healthcare Provider Details

I. General information

NPI: 1548004955
Provider Name (Legal Business Name): OMOBOLANLE OGUNSANYA PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 06/20/2024
Certification Date: 05/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

7805 REGENT DR
ARLINGTON TX
76001-7381
US

V. Phone/Fax

Practice location:
  • Phone: 903-921-9070
  • Fax:
Mailing address:
  • Phone: 903-921-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1116829
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: