Healthcare Provider Details

I. General information

NPI: 1780277269
Provider Name (Legal Business Name): DORINE OWEKE OWALLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2021
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9812 AMARANTH DR
FORT WORTH TX
76177-3217
US

IV. Provider business mailing address

9812 AMARANTH DR
FORT WORTH TX
76177-3217
US

V. Phone/Fax

Practice location:
  • Phone: 817-449-3005
  • Fax:
Mailing address:
  • Phone: 817-449-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number780817
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: