Healthcare Provider Details

I. General information

NPI: 1972201895
Provider Name (Legal Business Name): OMOTAYO THERESA GBENGAOJO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 05/26/2025
Certification Date: 05/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 HERITAGE PKWY STE 209
MANSFIELD TX
76063-2740
US

IV. Provider business mailing address

1312 LAWNVIEW DR
FORNEY TX
75126-1308
US

V. Phone/Fax

Practice location:
  • Phone: 817-523-8812
  • Fax:
Mailing address:
  • Phone: 903-922-5944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1110419
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: