Healthcare Provider Details

I. General information

NPI: 1174050603
Provider Name (Legal Business Name): AGNES U OLOLO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 05/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 STUART DR
LA PORTE TX
77571-3942
US

IV. Provider business mailing address

3802 STUART DR
LA PORTE TX
77571-3942
US

V. Phone/Fax

Practice location:
  • Phone: 281-478-6096
  • Fax: 281-478-6096
Mailing address:
  • Phone: 281-478-6096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP133617
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: