Basic Information
| Provider Information | |||||||||
| NPI: | 1184139362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OMOTAYO | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 MANOR LN | ||||||||
| Address2: | |||||||||
| City: | WAXAHACHIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751657533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145181398 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12221 MERIT DR STE 450 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727701032 | ||||||||
| FaxNumber: | 4694842126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2017 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/19/2017 | ||||||||
| NPIReactivationDate: | 02/07/2018 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP135407 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | AP135407 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.