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General NPI Number Information
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NPI Number | 1083200208
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Entity Type | Individual
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Provider Name | ETIDO J UDOSEN PMHNP-BC, CNP, MSN
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Gender | Male
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Dates
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Enumeration Date | 12/13/2020
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Last Update Date | 02/05/2023
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Provider Practice Location Address
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Address Line | 6160 WARREN PKWY STE 100
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City | FRISCO
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State | TX
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Zip | 75034-9415
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Country | US
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Telephone | 197-256-5397
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Fax |
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Provider Business Mailing Address
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Address Line | 6160 WARREN PKWY STE 100
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City | FRISCO
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State | TX
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Zip | 75034-9415
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Country | US
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Telephone | 972-565-3977
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 1021337
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License Number State | TX
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