Basic Information
| Provider Information | |||||||||
| NPI: | 1235377805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OYEFESOBI | ||||||||
| FirstName: | ADIAH | ||||||||
| MiddleName: | DIONNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | WHNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NWANKWO | ||||||||
| OtherFirstName: | ADIAH | ||||||||
| OtherMiddleName: | DIONNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | WHNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179230088 | ||||||||
| FaxNumber: | 8179245144 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 8TH AVENUE, SUITE 435 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179230088 | ||||||||
| FaxNumber: | 8179245144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2009 | ||||||||
| LastUpdateDate: | 02/05/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP117884 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 198502004 | 05 | TX | MEDICAID | 198502005 | 05 | TX | MEDICAID | 198502007 | 05 | TX | MEDICAID | 198502008 | 05 | TX | MEDICAID | 198502006 | 05 | TX | MEDICAID | 198502012 | 05 | TX | MEDICAID | 8Y9483 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 198502001 | 05 | TX | MEDICAID | 198502003 | 05 | TX | MEDICAID | 198502010 | 05 | TX | MEDICAID | 198502009 | 05 | TX | MEDICAID | 830N92 | 01 | TX | BCBS | OTHER | 198502002 | 05 | TX | MEDICAID |