Healthcare Provider Details

I. General information

NPI: 1851872816
Provider Name (Legal Business Name): ISAAC OLUFEMI OGUNSEYITAN PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 HULEN ST
FORT WORTH TX
76107-7277
US

IV. Provider business mailing address

819 HONTLEY DR
ARLINGTON TX
76001-6151
US

V. Phone/Fax

Practice location:
  • Phone: 817-569-4300
  • Fax:
Mailing address:
  • Phone: 817-703-5890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP139508
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: