Healthcare Provider Details

I. General information

NPI: 1306412192
Provider Name (Legal Business Name): ELIZABETH CHINYERE OGBONNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6363 N STATE HIGHWAY 161 STE 100
IRVING TX
75038-2239
US

IV. Provider business mailing address

4913 TREESIDE DR
FORT WORTH TX
76123-2948
US

V. Phone/Fax

Practice location:
  • Phone: 469-200-3272
  • Fax:
Mailing address:
  • Phone: 806-626-1619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1045643
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: