Healthcare Provider Details

I. General information

NPI: 1225686967
Provider Name (Legal Business Name): AMADEVBORO OKUNDAYE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 CYPRESSWOOD DR
SPRING TX
77379-7891
US

IV. Provider business mailing address

15507 TERRACE OAKS DR
HOUSTON TX
77068-2067
US

V. Phone/Fax

Practice location:
  • Phone: 281-803-5882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP140382
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: