Basic Information
| Provider Information | |||||||||
| NPI: | 1356996326 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENEBONG | ||||||||
| FirstName: | EDIOMI | ||||||||
| MiddleName: | EDET | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 GREENHOUSE RD STE 200B | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770847288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819933733 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24534 KINGSLAND BLVD # 220 | ||||||||
| Address2: | |||||||||
| City: | KATY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774943429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323215180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2019 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | AP142164 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.