Healthcare Provider Details

I. General information

NPI: 1982322814
Provider Name (Legal Business Name): OMOLOLA OLAMIDE FAGBOYEGUN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BAYSHORE DR
MANSFIELD TX
76063-6709
US

IV. Provider business mailing address

800 BAYSHORE DR
MANSFIELD TX
76063-6709
US

V. Phone/Fax

Practice location:
  • Phone: 817-262-0506
  • Fax:
Mailing address:
  • Phone: 817-262-0506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1089643
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: