Healthcare Provider Details

I. General information

NPI: 1568085074
Provider Name (Legal Business Name): OLIVIER BERTRAND DJOUMESSI PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 W RIVERSIDE AVE STE 5391
SPOKANE WA
99201-0580
US

IV. Provider business mailing address

4402 LONGBOURN DR
MANSFIELD TX
76063-2252
US

V. Phone/Fax

Practice location:
  • Phone: 817-230-3994
  • Fax:
Mailing address:
  • Phone: 817-230-3994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61420571
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number146076
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: