Healthcare Provider Details

I. General information

NPI: 1891441580
Provider Name (Legal Business Name): BASIL IBHAGBEMIEN UKE APRN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 05/04/2025
Certification Date: 05/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 OVERTON RIDGE BLVD
FORT WORTH TX
76132-3614
US

IV. Provider business mailing address

1406 EVERGLADES CT
ARLINGTON TX
76002-5112
US

V. Phone/Fax

Practice location:
  • Phone: 817-386-1537
  • Fax:
Mailing address:
  • Phone: 682-465-1740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1185947
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: