MEDICARE: OMIANA ABIOLA AJIBADE NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	AP129665	TX
2	363LA2200X	Adult Health Nurse Practitioner	AP129665	TX
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP129665	TX
4	363LP2300X	Primary Care Nurse Practitioner	AP129665	TX

General Provider Information

NPI Number	:	1598124190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMIANA ABIOLA AJIBADE NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	6720 BERTNER AVE STE P115
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-2604
Country	:	US
Telephone Number	:	832-355-3994
Fax Number	:

Provider Business Practice Location Address
First Line	:	9055 KATY FWY STE P200
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-1624
Country	:	US
Telephone Number	:	713-461-2915
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2016
Last Update Date	:	04/17/2026

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