Healthcare Provider Details

I. General information

NPI: 1396456174
Provider Name (Legal Business Name): CHRISTIANA UPE OMODUGBA-UDEH PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 W 10TH AVE
KENNEWICK WA
99336-6300
US

IV. Provider business mailing address

13355 NOEL RD STE 1100
DALLAS TX
75240-6694
US

V. Phone/Fax

Practice location:
  • Phone: 509-870-9150
  • Fax:
Mailing address:
  • Phone: 833-400-0120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61408400
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2022026825
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: