Healthcare Provider Details

I. General information

NPI: 1760148753
Provider Name (Legal Business Name): SOUMANA DJIBO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2021
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 DAVIS BLVD
SOUTHLAKE TX
76092-8244
US

IV. Provider business mailing address

3402 ROSEMEAD DR
ARLINGTON TX
76014-3557
US

V. Phone/Fax

Practice location:
  • Phone: 817-912-1771
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP141893
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: