Healthcare Provider Details

I. General information

NPI: 1497357206
Provider Name (Legal Business Name): ELIZABETH KERUBO OTUCHO PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 PINEWOOD DR
MCKINNEY TX
75071-8384
US

IV. Provider business mailing address

5409 PINEWOOD DR
MCKINNEY TX
75071-8384
US

V. Phone/Fax

Practice location:
  • Phone: 817-405-0586
  • Fax: 804-612-5201
Mailing address:
  • Phone: 817-405-0586
  • Fax: 804-612-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1019612
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: