MEDICARE: MRS. ABOSEDE OLUBUNMI GBAKINRO

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	1077320	TX
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1077320	TX

General Provider Information

NPI Number	:	1770330326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ABOSEDE OLUBUNMI GBAKINRO

Provider Business Mailing Address
First Line	:	3060 S CAMINO LAGOS
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-6743
Country	:	US
Telephone Number	:	817-637-2701
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 N WATSON RD STE 190
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76006-6225
Country	:	US
Telephone Number	:	817-637-2701
Fax Number	:

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

Provider Enumeration Date	:	05/01/2024
Last Update Date	:	05/01/2024

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