Healthcare Provider Details

I. General information

NPI: 1508057282
Provider Name (Legal Business Name): MERCY OTUOMAGIE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 S BROADWAY ST
LA PORTE TX
77571-5327
US

IV. Provider business mailing address

1009 S BROADWAY ST
LA PORTE TX
77571-5327
US

V. Phone/Fax

Practice location:
  • Phone: 281-471-4202
  • Fax:
Mailing address:
  • Phone: 281-471-4202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number579705
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: