Basic Information
| Provider Information | |||||||||
| NPI: | 1144411588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELEGONYE | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650865 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155000 | ||||||||
| FaxNumber: | 9727159976 | ||||||||
| Practice Location | |||||||||
| Address1: | 6606 LBJ FWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752406533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155000 | ||||||||
| FaxNumber: | 9727159976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2007 | ||||||||
| LastUpdateDate: | 03/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 616142 | TX | N | Nursing Service Providers | Registered Nurse | 367500000X | AP116669 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 191783303 | 05 | TX | MEDICAID | 191783304 | 05 | TX | MEDICAID | P00785620 | 01 | TX | RAILROAD | OTHER | 191783305 | 01 | TX | MEDICAID CSHCN | OTHER | 89675U | 01 | TX | BCBS | OTHER |