Healthcare Provider Details

I. General information

NPI: 1750141214
Provider Name (Legal Business Name): ELIZABETH A OWOLABI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 S 5TH ST
WACO TX
76798-1435
US

IV. Provider business mailing address

16610 FOSTER POINT LN
HOUSTON TX
77095-5519
US

V. Phone/Fax

Practice location:
  • Phone: 832-215-0740
  • Fax:
Mailing address:
  • Phone: 832-215-0740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: