Healthcare Provider Details

I. General information

NPI: 1639756760
Provider Name (Legal Business Name): OMOTOLA IYABO JOHNSON PMHNP BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 FANNIN ST
HOUSTON TX
77002-9114
US

IV. Provider business mailing address

2420 FANNIN ST
HOUSTON TX
77002-9114
US

V. Phone/Fax

Practice location:
  • Phone: 832-831-3651
  • Fax: 832-831-3652
Mailing address:
  • Phone: 832-831-3651
  • Fax: 832-831-3652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1032755
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: