Healthcare Provider Details

I. General information

NPI: 1467212282
Provider Name (Legal Business Name): ROSELYN OMUNGO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12881 N IH 35
LIVE OAK TX
78233-2966
US

IV. Provider business mailing address

12881 N IH 35
LIVE OAK TX
78233-2966
US

V. Phone/Fax

Practice location:
  • Phone: 210-742-6555
  • Fax:
Mailing address:
  • Phone: 210-742-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1155605
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1155605
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: