Healthcare Provider Details

I. General information

NPI: 1497367882
Provider Name (Legal Business Name): IKENNA CHIMAEZE OGOBUIRO DNP, MBA, CRNA, APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 07/28/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 PLACITAS TRL
FORT WORTH TX
76131-1506
US

IV. Provider business mailing address

1761 PLACITAS TRL
FORT WORTH TX
76131-1506
US

V. Phone/Fax

Practice location:
  • Phone: 214-874-8516
  • Fax:
Mailing address:
  • Phone: 214-874-8516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number845025
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1166576
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: