Healthcare Provider Details

I. General information

NPI: 1215307715
Provider Name (Legal Business Name): KEYNA OMENUKOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 REPUBLIC PKWY STE 190
MESQUITE TX
75150-6902
US

IV. Provider business mailing address

1675 REPUBLIC PKWY STE 190
MESQUITE TX
75150-6902
US

V. Phone/Fax

Practice location:
  • Phone: 972-576-7399
  • Fax: 972-476-0006
Mailing address:
  • Phone: 972-576-7399
  • Fax: 972-476-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP128934
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP128934
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024286045
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61500520
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: