Healthcare Provider Details

I. General information

NPI: 1447910427
Provider Name (Legal Business Name): OMOLADE OGUNGBADE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2021
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10058A LONG POINT RD
HOUSTON TX
77055-4002
US

IV. Provider business mailing address

4031 FM 1463 RD STE 40-244
KATY TX
77494-5963
US

V. Phone/Fax

Practice location:
  • Phone: 832-380-3980
  • Fax: 832-380-3985
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1058692
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: